Infection after cyanoacrylate injection: a fatal complication in a patient with portal hypertension associated with common variable immunodeficiency.

2002 because of recurrent pneumonitis associated with bronchiectasis. Common variable immunodeficiency was diag− nosed (the serum gammaglobulin level was 0.09 g/dL [normal range 1.2± 1.5 g/ dL]), and she was treated with immuno− globulins. In 2004, gastroscopy revealed stage 2 esophageal and gastric varices, caused by nodular regenerative hyperpla− sia−related portal hypertension. In 2005 the patient developed Pseudomonas aeru− ginosa pneumonitis. In February 2006, endoscopic injection sclerotherapy with cyanoacrylate glue injections was per− formed for gastric variceal bleeding, with antibiotic prophylaxis with cefazoline. In April 2006 she had another hematemesis and further endoscopic injection sclero− therapy was required. In May 2006, it was believed that she had developed an infection associated with the cyanoacrylate glue on the basis of the following features: (a) she had a fever and this began after the cyanoacrylate injec− tion; (b) bronchial bacteriology was neg− ative; (c) there was persistent sepsis, with blood samples positive for P. aerugi− nosa despite prolonged and specific anti− biotic therapy; and (d) the findings of po− sitron emission tomography using 18F− fluorodeoxyglucose (18F−FDG) radiotracer, with uptake at the location of the sclero− therapy (see l" Figure 1). Eventually, the patient was treated with meropenem and colimycin. Gastrectomy, porto±caval anastomosis, and thrombectomy of the splenic vein were performed. Multiresis− tant P. aeruginosa was isolated from all samples, including the cyanoacrylate thrombus. The patient died from intract− able septic shock. Fatal complications of endoscopic injec− tion sclerotherapy, such as glue embo− lism, are rare [1]. Septicemia after endo− scopic injection sclerotherapy has been reported in only a few patients who had received the recommended prophylactic antibiotics [2]. The majority of hypogam− maglobulinemic patients suffer from bronchiectasis as a result of recurrent pulmonary sepsis [3]. The “usual” entero− bacterial antibiotic prophylaxis (e. g. with cefazolin) might not be suitable in pa− tients with bronchiectasis, especially in the setting of common variable immuno− deficiency [4]. Of note in our patient, we were able to pinpoint the site of the infec− tion in the glue using 18F−FDG positron emission tomographic imaging [5]. In conclusion, sclerotherapy with cyano− acrylate in patients with portal hyperten− sion related to common variable immu− nodeficiency entails a specific risk of fatal sepsis, despite antibiotic prophylaxis and immunoglobulin treatment.