Endotipsitis in a liver transplant patient: the role of positron emission tomography in a challenging diagnosis

Endotipsitis is a rare but serious infection of TIPSS, with no established diagnostic criteria or treatment guidelines. It presents significant diagnostic challenges, particularly in immunocompromised patients such as liver transplant recipients. We report the case of a patient who underwent liver transplantation followed shortly thereafter by TIPSS placement due to refractory ascites (PSVD of the liver graft). He presented 10 years after with decompensation of cirrhosis and fever. Despite negative blood cultures, FDG PET-CT revealed intense hypermetabolism along the TIPSS suggesting endotipsitis. He was treated initially with antibiotics and required ultimately a liver retransplantation. This case is notable for its occurrence in a transplant recipient, the absence of bacteremia, and the extremely delayed onset after TIPSS placement, the longest interval reported to date. Diagnosis was made through PET-CT, highlighting its critical role when conventional investigations are inconclusive.