Gold, J.

Isaacson, C.

Rudinsky, H.

English

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514 S.A. ,MEDICAL JOURNAL 2 June 19565. Andrews, G. W. S., Pickering, G. W. en Sellors, T. H. (1948):Quart. J. Med., 17, 291. .6. Holman, E. en WilJet, F. (1951): J. Amer. Med. Assoc.,146, I.7. Phillips, W. L. (1956): S. Afr. T. Geneesk., 30, 37.8. Mortensen, V. en Warburg, E. (1948): Acta med. scand.,131,203.9. Deterling, R. A. en Humphreys, C. H. (1955): Circulation,12,30.10. Hansen, A. T., Eskildsen, P. en Gotzche, H. (1951): Ibid.,3,881. ,11. McKusick, V. A. (1952): Bull. Johns Hopk. Hosp., 90, 3.12. J;:liasch, H., Lagerlof, H. en Werko, L. (1950): Nord. med.,44, 1128. •13. Yu, P. N. G., Lovejoy, F. W., Joos, H. A., Nye, R. E. enMahoney, E. B. (1953): Circulation, 7, 102.14. Gunnar, R. M., DiIlon, R. F., Wallyn, R. J. en Elisberg, E. T.(1955): Ibid., 12, 827.SUPPURATIVE PYLEPHLEBITIS OF THE PORTAL VEIN FOLLOWING AMUCOCELE OF THE APPENDIX~. RUDINSKY, M.B., B.CH. (RAND)*C. IsAACSON, M.B., B.CH. (RAND)!J. GOLD, M.B., B.CH. (RAND)tBaraglVanath Non-European Hospital, JohannesburgSuppurative pylepWebitis of the portal vein is acomparatively rare condition. The commonest precedinglesion is acute appendicitis. In 44 .cases reported byEliason,l acute appendicitis was found in 40, and in3 of 4 cases described by Koster and Kasman.2 It is,however, a rare complication of appendicitis, occurringin only O' 5 %of cases.! Cases have also been reported inassociation with diseases of the stomach, rectum,pancreas, spleen, gall-bladder and mesenteric lymphnodes.Rolleston and McNee3 regarded the following featuresas being those of major clinical significance: (1) Evidenceof primary cause, (2) .picture of sepsis (especially rigorsand sweats) and (3) evidence of involvement of theliver.Although a fair number of cases have been reportedin Europeans4 ,5,6,7 we have not been able to find anyreference to a case in an African. At this hospital over aperiod of? years there have been over 180,000 admissions,included in which were 740 cases of appendicitis. Nocase of suppurative pylephlebitis has however occurred.We therefore wish to record this case in an Africanpatient.CASE REPORTAn adult African male (Sotho) aged about 68 years; a factoryhand, was admitted to this hospital on 11 July 1955, complainingof cough, hiccough and pain in the right chest for 2 weeks.He had been born in the vicinity of Johannesburg and hadnever left the environs of the city. Several months before ad-mission he had an attack of pain in the right iliac fossa, but thisdisappeared after about one week. He also reported an episodeof swelling of the left foot in 1951 and some 'chest trouble' in1953.Positive findings on admission included elevated temperature(l02°F); an injected pharynx; a blood pressure of 100/50 mm. Hg;an enlarged, tender liver, palpable 3t inches below the rightcostal margin, with a smooth, firm edge; a firm non-tender en-larged spleen, palpable I inch I:ielow the left costal margin. Therewas no tenderness in the right iliac fossa, nor was any mass felt.There was no clinical jaundice on admissioQ. Laboratoryfindings showed serum bilirubin 2· 7 mg. per 100 c.c. with a positivedirect v. d. Bergh reaction; blood proteins 6 g. per 100 c.c.(albumin 2· 2, globulin 3·9); alkaline phosphatase 12· 6 King-* Medical Registrar.t Registrar Pathologist 'of South African Institute for MedicalResearch'.t House Physician.Armstrong units; blood urea 52 mg. per 100 C.C.; haemoglobin11 . 6 g. per 100 C.C., with a leucocytosis of 16,500 per c. mm.,of which 89% were neutrophils and 11 % lymphocytes; malariasmears were negative. The urine showed 1+ bilirubin and 2+urobilin. Urine and stool exanIinations for parasites were negative.X-ray studies showed increased striation at" both hilar regionsand at -the right base, with peaking of the right diaphragm, prob-ably due to old pleural thickening. In addition the liver appearedenlarged. Despite the absence of E. histoly/ica in the stools itwas felt that the possibility of amoebiasis could not be excludedand the patient was therefore given 1 gr. of emetine daily for 10days, and penicillin 500,000 units 6-hourly. At the end of 2 weeksthere was no improvement in 'his condition.Blood chemistry studies on 27 July revealed a slight fall inthe serum bilirubin to 0·6 g. % but no other significant change.Semlogic tests for typhoid, melitensis and rickettsiae were nega-tive. Rigors became pronounced (temperature ranging fromIOl c to 103°F), and his condition deteriorated, with 10!iS of appe-tite and listlessness.-Blood cultures were repeatedly sterile. Intra-venous therapy (dextrose and saline) was commenced, with theaddition of hydro-cortisone as a supportive measure. He was alsogiven 1 g. of intra-muscular streptomycin daily and 200 mg.of isoniazid orally tds.On 8 August he became clinically jaundiced and markedlydisorientated (serum bilirubin 3·4 mg. %). Examination of thecerebrospinal fluid was essentially negative and a repeat haemo-gram still showed a leucocytosis. In a search for pus the liver wasneedled, but with negative results and a pneumo-peritoneumshowed the liver to be completely free of the diaphragm.The patient continued to deteriorate and died in a semi-comatose .condition 5 weeks after admission.Post-mar/em FindingsPeritoneal cavity contained 2 pints of dark-brown fluid.Bowel. There was marked dilatation of the appendix, whichmeasured 3 inches in length and t inch in diameter and on sectioncontained a large quantity of greenish-white mucoid materialwhich compressed and thinned the wall. The features were thoseof a mucocele. The remainder of the bowel was normal.Liver. This organ was slightly enlarged (weight 1,700 g.) andhad a smooth surface. On section numerous acute abscesseswere seen throughout the parenchyma, varying in size from 1 to5 mm. in diameter and containing greenish-white muco-pus.These abscesses were surrounded by a narrow zone of congestedand compressed liver tissue; the surrounding liver-parenchymaappeared normal. The portal vein contained a large septic thrombuslooselv adherent to the wall of the vein about I! inches from theporta -hepatis, and also large quantities of light-ireen pus. Septicthrombi were present in the superior mesenteric vein, but not inthe splenic vein.Lungs. Both showed severe .congestion and oedema.Microscopic ExaminationAppendix. The distended appendix was filled with homogeneousmucinous mat..:rial. At one point the muscularis was ruptured.2 Junie 1956 S.A. TYDSKRIF VIR GENEESKUNDE 515There was compr~s\on. and thinning of the wall, with areas ofcomplete I~ss <?f,e~lthehum and atrophy of the lymphoid follicles.The. subeplthelia, tissues showed fibrosis, with foci of fatty meta-plasH~; an~ were. diffusely infiltrated by chmnic inflammatorycells m which chams of Gram-positive cocci were observed. Thefeatures were those of a chronic obliterative appendicitis withthe formatIon of a mucocele (Fig. I).Fig. I. Section of the appendix, showing the lumen lined bymucus-secreting cells and containing homogeneous mucinousmaterial. The muscularis is Tuptured with the formation of alarge mucocele lined by a thin layer of fibrous tissue. Haema-toxylin and eosin x 7.Liver. Section of the liver showed the presence of several largeacute abscesses lined by degenerating and compressed liver ce!lsand containing necrotic debris densely infiltrated by polymorphs.In some instances it was clear that the abscesses were related tothe branches of the portal vein. Chains of Gram-positive cocciwere observed in the abscesses. The su;rounding liver parenchymashowed marked peri portal haemosiderosis with slight associatedfibrosis and chronic inflammatory-cell infiltration (Fig. 2).Lungs. Section showed the presence of bronchopneumonia,congestion and oedema.Summary of Post-mortem FindingsI. Chronic obliterative appendicitis with the formation of amucocele.2. Suppur,ative pylephlebitis of the porta I vein.3. Multiple abscesses of the liver.Fig. 2., Section. of the' liver showing the presence of a largeacute abscess hned by degenerating and compressed liver-cells and containing necrOtic debris densely inflltrated bypolymorphs. Haematoxylin and eosin x 120.SUMMARYA case of suppurative pylephlebitis of the portal veinfollowing a mucocele of the appendix is described in anAfrican patient admitted to the Baragwanath Non-European Hospital.Acknowledgments are made to Dr. J. D. Alien, Medical Super-intendent, Baragwanath non-European Hospital, for permissionto publish this cas.e and for the use of hospital records, to Dr.V. H. Wilson, Senior Physician of the hospital for advice andhelp in the preparation of this paper. and to the photographicdepartment of the South African Institute for Medical Researchfor the photomicrographs.REFERENCESI. Eliason, E. L. (1926): Surg. Gynec. Obstet., 42, 510.2. Koster, H. and Kasman, L. P. (1933): Arch. Surg., 27, 910.3. Rolleston, H. and Mc ee, J. W. (1929): Diseases of the LiverGall Bladder and Bile Dllcts, 3rd ed., p. 118. London: Mac~Millan.4. Bakst, H. J. and Jeghers, H. (!937): Amer. .1. Med. Sci. 193690. ' ,5. Massachusetts General Hospital case record (1953): NewEngl. J. Med., 249, 900.6. C1ark, C. W. and Bunn, P. A. (1933): .Y. SI. J. Med., 53,3007.7. Seife, M. and Lisa, .I. R. (1950): Amer. .T. Trop. Med., 30, 769.I _

Suppurative pylephlebitis of the portal vein following a mucocele of the appendix

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Suppurative pylephlebitis of the portal vein following a mucocele of the appendix

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