We present a case of persistent P. aeruginosa bacteraemia secondary to NCBA infection that was successfully treated with a sequential surgical treatment, orthotopic liver transplant followed vertical gastrectomy with prolonged systemic antibiotic therapy.

Variceal cyanoacrylate injection has been reported to cause transient bacteraemia with no subsequent complications [4]. However, recurrent bacteraemia is a rare complication and only ten cases have been reported to the date in the literature [6,7,8,9,10,11,12,13]. Three of the ten reported cases died despite effective antibiotics. The physiopathology is not well understood, but the hypothesis is that disruption of the mucosa in the upper gastrointestinal tract after the injection of a cyanoacrylate plug promotes the passage of viable bacteria. Additionally, NCBA forms a large conglomerate providing an ideal niche for bacterial growth. Other theories have been postulated such as the previous contamination of the needle or the side channel of the endoscope [9]. All the reported cases in the literature were men except one woman [7]. They all presented with bleeding gastric varices secondary to cirrhosis and/or portal hypertension and received an effective antibiotic treatment with different duration (2–24 weeks). However, only four underwent surgery: a 60-year-old and a 77-year-old patient who underwent surgical debridement of the cyanoacrylate plug and a partial gastrectomy, respectively. Unfortunately, both died few days after the surgery [6, 10]. In a third case, a 54-year-old woman, died from septic shock despite multiple antibiotic treatments, a gastrectomy and a thrombectomy of the splenic vein [7]. The timeline of these events, however, is not clearly defined. The last one was a 46-year-old patient who also underwent a liver transplant with no initial control of the infection source and recurrent bacteraemia 10 days after the transplant, achieving clearance of the bacteraemia [9].

Our case is unique because of several facts. Firstly, this is the second case of P. aeruginosa reported as the etiological agent of NCBA infection, and ours represents the fourth reported patient in which the cyanoacrylate plug was surgically removed [6, 7, 10]. Secondly, a two-step approach with liver transplant in order to reduce portal hypertension and partial gastrectomy as an effective treatment in the same patient has not been documented elsewhere in the literature.

Furthermore, PET-CT scan has been only performed in three other cases and it should be considered as a useful tool for its diagnosis [7, 11, 13].

Our patient is the youngest reported case, which likely contributed to his survival of two high-risk surgical procedures. Last, this case highlights the importance of source control, which is fundamental in managing uncontrolled sepsis.