Pediatr Emerg Med J.  2023 Oct;10(4):169-174. 10.22470/pemj.2023.00801.

A pediatric case of portosystemic shunt presenting hypoxemia with brain abscess in an emergency department

• Hwang ST
• Park JS

• KMID: 2546293
• DOI: http://doi.org/10.22470/pemj.2023.00801

Abstract

Portosystemic shunt is a rare congenital vascular anomaly. The shunt is hard to clinically suspect because its symptoms develop insidiously and affect various systems at different time points. We report a case of an 11-year-old girl who presented with brain abscess and hypoxemia without respiratory distress. No abnormality related to the hypoxemia, such as intracardiac shunt, was found on the initial chest radiograph and echocardiogram. However, computed tomography showed a portosystemic shunt. An intrapulmonary shunt was demonstrated by bubble contrast echocardiography, indicating a grade 2 hepatopulmonary syndrome, a complication of portosystemic shunt. This case describes the diagnostic process of an unusual case presenting neurological abnormalities and hypoxemia without respiratory distress. Portosystemic shunt with hepatopulmonary syndrome should be considered in the differential diagnosis of unexplained hypoxemia.

Keyword

Brain Abscess; Hepatopulmonary Syndrome; Hypoxia; Portal Vein; Portosystemic Shunt, Surgical

Figure

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  Fig. 1. T1-weighted brain magnetic resonance imaging (day 1) showing a 2 × 2 cm-sized, irregular rim-enhancing lesion in the left frontal lobe. The lesion also shows a perilesional edema and restricted diffusion.

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  Fig. 2. Contrast-enhanced computed tomography scans (day 1) showing the portal vein (arrows, A), portosystemic shunt (arrowheads, B and C), and hepatic vein (arrows, D). The colors of the arrows and arrowheads indicate the sides (black for right and white for left).

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  Fig. 3. Bubble contrast echocardiogram. On this apical 4-chamber view, microbubbles (arrowheads) are seen entering the left atrium through the pulmonary veins, consistent with an intrapulmonary shunt.

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  Fig. 4. Direct portogram. It shows a massive intrahepatic portosystemic shunt via the right portal vein (white arrow) to the right hepatic vein (black arrow) with minimal intrahepatic parenchymal portal vein flow.

Reference

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