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Septic thrombophlebitis of the superior hemorrhoidal venous plexus
SEPTIC THROMBOPHLEBITIS HEMORRHOIDAL STREPTOCOCCEMIA,
VENOUS PLEXUS*
CEREBRAL SAUL
EMBOLUS AND RECOVERY
SCHAPIRO,
BROOKLYN,
T
HE mechanism by which emboIi are deposited into the arteria1 system from periphera1 Venus thrombi has aIways been the subject of medica specuIation. Some of the accepted routes are (I) the congenital heart,‘j2z3 (2) cIumps of bacteria passing through wide puImonary capiIIaries,4 and (3) acute endocarditis secondary to phIebitis.6 Cerebra1 emboIi through these pathways have been reported, but as a compIication of recta1 disease they are extremeIy rare. The Iiterature contains onIy one proved and one suspected case. 6.7The patient whose case is reported here deveIoped cerebra1 emboIi foIIowing a thrombophIebitis of the rectum. An associated streptococcemia was treated successfuIIy with suIfaniIamide. CASE
OF THE SUPERIOR
REPORT
The patient was a 35 year oId white maIe who had had intermittent recta1 bleeding for two years. Three years before the present iIlness he had had a gonorrhea1 infection. There were no other significant iIInesses and his famiIy history was irreIevant. Two days before hospital admission he feIt pain in the rectum and consuIted his physician who supposedIy incised “a boil in the rectum.” Upon his return home, he began to have sharp, steady lower abdomina1 pain. The next morning, his temperature rose, he became chilly, and vomited twice. A consuItant made a diagnosis of a recta1 abscess. Morphine sulfate was given for the reIief of abdomina1 pain, but the patient’s condition faiIed to improve. The temperature rose to IO~F., and he became incoherent, disoriented, and unresponsive. On examination in the hospita1, the patient appeared acutely ill, spoke incoherentIy, was stuporous, and perspired profuseIy. Mouth
NEW
M.D. YORK
temperature was 104F., pulse 130, respirations 26, and bIood pressure 100/68. The pupils were contracted, but reacted to Iight and accommodation. No crania1 nerve involvement was found, nor was there any nuchal rigidity. The heart and Iungs showed no abnormalities. The abdomen was soft, but markedIy tender throughout. There were no paIpabIe masses or muscIe rigidity. The bIadder was percussed to just beIow the umbiIicus, and on catheterization 28 ounces of cIear urine were obtained. DigitaI examination of the rectum caused excruciating pain and the sphincter was markedIy spastic. There was a smaII amount of free bIeeding. Just above the anorecta1 Iine and on the right waI1 there was a soft sweIIing extending “finger-Iike” upward and Iost to the reach. Proctoscopy was incompIete because of the patient’s irrationa1 state. However, just beIow the sweIIing, there was seen a bIeeding, ragged, necrotic uIcer about I cm. in diameter. HemogIobin was 80 per cent; red bIood ceIIs 4,300,000 per c.mm.; white bIood ceIIs 7,600 per c.mm. with a norma differentia1 count. The Wassermann reaction was negative, the urine normaI. BIood sugar was 152 mg. per IOO c.c., and bIood urea 12.3 mg. per IOO C.C. The sedimentation rate was 67 mm. per hour
(Westergren method). BIood cuIture showed five coIonies of Streptococcus bemolyticus. The patient was given a hypodermocIysis of IOOO C.C. of 5 per cent gIucose in saline. His genera1 condition became worse and the next day, the fourth day of his illness, tremors of the right Ieg and right facia1 weakness were noted. His face was flushed and there was cyanosis of the Iips and finger nails. He again became incoherent and sIept restIessIy for Iong intervaIs. Repeated catheterization was necessary. MedicaI opinion at the time was that a thrombotic hemorrhoidal vein, paIpabIe at the interna sphincter and extending up the recta1 waI1, had spread from this IocaI focus into a
* Read before the New York ProctoIogicaI Society, February 2, 445
1939.
446
* me&an
Journal
of Surgery
Schapiro-Recta1
ThrombophIebitis
FEBRUARY, rgqr
f. Ei?TEERAL ART SUBCLAV ART.
I. 2. 3, 4. ’ 5. 6.
.‘-.;.,:
_ THROMBOPHLEBITIS. PULMONARY EhjBOLUS. CEREBRAL EMBOLUS. PATENT FORAMEN WALE. ~ PATENT DUCT ART INT. VENTRICULAR DEFEC’I:
--SUPERIOR
%IDDLE
HEM. VEIN
HEM. VEIN
s’
FIG. I. Schematic drawing illustrating the various pathways of emboli from the veins of the rectum. The arrows indicate the course taken by a rectal emboIus (I) through the inferior vena cava into the right heart and pulmonary artery into the lung, (2) eventuaIly absorbed here by the venous capillaries and passed into the pulmonary vein, thence through the left heart into the aorta and then to the brain or (3) other arterial branches. The “paradoxica1 embolism” is made possibIe when there is present either (4) patent foramen ovaIe, (5) patent ductus arteriosus, or (6) interventricular defect.
NEW
SERVESVOL. LI, No.
z
Schapiro-Recta1
systemic infection, with possible numerous small emboli Iodged in the cerebrum. The high temperature, the profound prostration, the cerebra1 drowsiness and rapid pulse a11 indicated a grave prognosis. SuIfaniIamide, gr. IO, every three hours was immediateIy started. Improvement was noted late the next afternoon. The patient recovered from his drowsiness and was mentaIIy alert. The temperature dropped from 104 to IO~F., but toward evening, the patient again became irrational and complained of a severe headache. Recta1 examination at this time showed that posterior to and to the left of the thrombosed area previousIy described, there was a prominent, boggy sweIIing merging with the former mass. This was considered a rectal abscess. During the night, the abscess apparentIy perforated and six loose stools were passed. The temperature subsided to IOIF. and the rectal mass was considerably reduced in size. For the next three days steady improvement occurred aIthough the facia1 paresis, headache, and periods of disorientation persisted. The temperature decIined toward normal, and the blood culture at this time was steriIe. Accordingly, the dosage of sulfanilamide was reduced from 80 to 40 gr. daily. On the eIeventh day of illness, the patient’s condition was definiteIy better in spite of the persistence of headache and drowsiness. The recta1 mass had compIeteIy disappeared and there was no pain in the area. On discharge from the hospital on the seventeenth day, he was symptom-free but the right facia1 weakness and hyperactive reflexes remained. A neuroIogic examination, thirteen months later reveaIed the gait and station steady, the coFrdination intact, the sense of smeI1 and taste norma and the vision good. There was no nystagmus or diplopia. A definite overactivity of the Ieft side of the face was noted on speaking, whiIe the right side drooped. The tongue deviated to the Ieft. Deep reflexes were present, the right side much more active than the Ieft. An equivoca1 Babinski was present on the right side. COMMENT
Thrombosis of the inferior hemorrhoida vein is seen reguIarIy whereas in’volvement of the superior hemorrhoidal plexus is comparativeIy infrequent.* Fortunately,
ThrombophIebitis
American ~~~~~~~ of surgery
447
thrombophIebitis is not often a compIication of thrombosis in this region. When it does occur, infected emboIi may be disseminated.4 EmboIi from the hemorrhoidal veins usually terminate in the puImonary vesseIs. (Fig. I .) However, Boydg states, “ It occasionaIIy happens that an emboIus arising in a vein Iodges in an artery other than the puImonary artery. Such an emboIus must therefore have reached the Ieft side of the heart, aIthough carried by the veins to the right side. This occurrence, known as paradoxica1 emboIism, has aIways been more or Iess of a puzzle. The most important exampIe is afforded by puerpera1 hemipIegia. The usual expIanation given is that the embolus has passed through a patent foramen 0vaIe.” Rostan,” in a study of 71 I autopsies, found 139 with patent foramen ovale, of which seven cases had paradoxica1 embolism, three being cerebraI. Rabinowitz et aI.‘O coIIected eIeven cases of cerebral emboIus in congenita1 heart disease. NevertheIess, it does not seem plausible to expIain every case of cerebra1 emboIus on the basis of a congenita1 heart. Many of these cases may be instances of thrombophlebitis of a cerebra1 vesse1 due to clumps of bacteria having passed through the rather wide puImonary capiIIaries.4 Necropsy in cases of puerpera1 hemipIegiag has shown a secondary endocarditis on the left side of the heart, the vegetations having formed the source of the cerebra1 emboIi. FinaIIy infarction of the Iung may be foIIowed by thrombosis of the puImonary veins, which in turn may be responsibIe for emboIic phenomena in the cerebra1 circuIation. AIthough puImonary embolism foIlowing recta1 pathoIogy is not uncommon, serious resuIts are found in comparatively few cases. The doubIe bIood suppIy to the Iung coming from the bronchial and puImonary arteries (-Fig. I) tends to prevent infarct formation. Newman7 reported five cases of puImonary embolism folIowing hemorrhoidectomy, one foIIowing the injection of quinine and urea, and one case folIowing
448
American
Journal
of Surgery
Schapiro-Recta1
sigmoidoscopy. Cain8 and SzanceP aIso noted pulmonary emboIism as a compIication of thrombophlebitis of the hemorrhoida pIexus. However, cerebra1 emboIism foIIowing recta1 disease is extremeIy rare. A very carefu1 search of the Iiterature reveaIed but one substantiated by autopsy reported by Ohm6 in IgoT. His patient had a thrombophIebitis of the hemorrhoida pIexus which gave rise to repeated cerebral emboli. The patient died and post-mortem examination reveaIed a patent foramen 0vaIe. Newman’s patient deveIoped a hemipIegia immediateIy after a simpIe ana fistuIectomy. SUMMARY I. A case of thrombophIebitis of the superior hemorrhoidal venous plexus followed by a Streptococcus hemolyticus septicemia and cerebra1 emboli is presented. 2. It is our opinion that emboIi from the infected thrombus in the rectum Iodged in the Iungs, fltered through the wide puImonary capiIIaries and passed into the arteria1 circuIation of the brain. The absence of apparent endocardia1 changes and signs of a congenita1 heart Iesion tend to support this view.
ThrombophIebitis 3. Rapid and spectacuIar recovery forIowed the administration of Iarge doses of suIfaniIamide. 4. As far as can be determined this is the first case of its kind on record. REFERENCES I. ABBOTT, M. E., LEWIS, D. S., and BEATTIE, W. W.
Cerebral embolism, differential study of pulmonary stenosis and pulmonary atresia of developmental origin, and death from paradoxical cerebral embolism in 3 cases. Am. J. M. SC., 165 : 636, 1923. 2. THOMPSON, T., and EVANS, W. Paradoxical embolism. Quart. .I. Med., 23: 135, 1930. 3. HIRSCHBOECK, F. J. Paradoxical embolism with patent foramen ovale. Am. J. M. SC., 189: 236, 1935. 4. DACOSTA, J. C. Modern Surgery. Philadelphia, 1920. W. B. Saunders Company. 5. ROSTAN, A. Contribution B [‘etude de l’embolie croisee consecutive a la persistence du trou de batal. These de Genke, 1884. 6. OHM, J. Klinische Beobachtungen bei offenem Foramen Ovale deren diagnostischen und Bedeutung. Ztscbr. f. klin. Med., 61: 374, 1907. 7. NEWMAN, S. E. Thrombosis and embolism. Am. Proct. Sot., p. 23. 1931. 8. CAIN, A. Suprahemorrhoidal thrombophlebitis of rectum. Pratt. Med., 17: 202, 1936. g. BOYD, WILLIAM. Surgical Pathology. Philadelphia, 1929. W. B. Saunders Company. IO. RABINOWITZ,M. A., WEINSTEIN, J., and MARCUS. Paradoxical brain abscess in congenital heart disease. Am. Heart J., 7: 790, 1932. I I. SZANCER,H., and ZIELINSKI, T. Thrombophlebitis of hemorrhoidal pIexus with embolism of pulmonary artery. Polska gaz. lok., 6: I I, 1927.
VENOUS PLEXUS*
CEREBRAL SAUL
EMBOLUS AND RECOVERY
SCHAPIRO,
BROOKLYN,
T
HE mechanism by which emboIi are deposited into the arteria1 system from periphera1 Venus thrombi has aIways been the subject of medica specuIation. Some of the accepted routes are (I) the congenital heart,‘j2z3 (2) cIumps of bacteria passing through wide puImonary capiIIaries,4 and (3) acute endocarditis secondary to phIebitis.6 Cerebra1 emboIi through these pathways have been reported, but as a compIication of recta1 disease they are extremeIy rare. The Iiterature contains onIy one proved and one suspected case. 6.7The patient whose case is reported here deveIoped cerebra1 emboIi foIIowing a thrombophIebitis of the rectum. An associated streptococcemia was treated successfuIIy with suIfaniIamide. CASE
OF THE SUPERIOR
REPORT
The patient was a 35 year oId white maIe who had had intermittent recta1 bleeding for two years. Three years before the present iIlness he had had a gonorrhea1 infection. There were no other significant iIInesses and his famiIy history was irreIevant. Two days before hospital admission he feIt pain in the rectum and consuIted his physician who supposedIy incised “a boil in the rectum.” Upon his return home, he began to have sharp, steady lower abdomina1 pain. The next morning, his temperature rose, he became chilly, and vomited twice. A consuItant made a diagnosis of a recta1 abscess. Morphine sulfate was given for the reIief of abdomina1 pain, but the patient’s condition faiIed to improve. The temperature rose to IO~F., and he became incoherent, disoriented, and unresponsive. On examination in the hospita1, the patient appeared acutely ill, spoke incoherentIy, was stuporous, and perspired profuseIy. Mouth
NEW
M.D. YORK
temperature was 104F., pulse 130, respirations 26, and bIood pressure 100/68. The pupils were contracted, but reacted to Iight and accommodation. No crania1 nerve involvement was found, nor was there any nuchal rigidity. The heart and Iungs showed no abnormalities. The abdomen was soft, but markedIy tender throughout. There were no paIpabIe masses or muscIe rigidity. The bIadder was percussed to just beIow the umbiIicus, and on catheterization 28 ounces of cIear urine were obtained. DigitaI examination of the rectum caused excruciating pain and the sphincter was markedIy spastic. There was a smaII amount of free bIeeding. Just above the anorecta1 Iine and on the right waI1 there was a soft sweIIing extending “finger-Iike” upward and Iost to the reach. Proctoscopy was incompIete because of the patient’s irrationa1 state. However, just beIow the sweIIing, there was seen a bIeeding, ragged, necrotic uIcer about I cm. in diameter. HemogIobin was 80 per cent; red bIood ceIIs 4,300,000 per c.mm.; white bIood ceIIs 7,600 per c.mm. with a norma differentia1 count. The Wassermann reaction was negative, the urine normaI. BIood sugar was 152 mg. per IOO c.c., and bIood urea 12.3 mg. per IOO C.C. The sedimentation rate was 67 mm. per hour
(Westergren method). BIood cuIture showed five coIonies of Streptococcus bemolyticus. The patient was given a hypodermocIysis of IOOO C.C. of 5 per cent gIucose in saline. His genera1 condition became worse and the next day, the fourth day of his illness, tremors of the right Ieg and right facia1 weakness were noted. His face was flushed and there was cyanosis of the Iips and finger nails. He again became incoherent and sIept restIessIy for Iong intervaIs. Repeated catheterization was necessary. MedicaI opinion at the time was that a thrombotic hemorrhoidal vein, paIpabIe at the interna sphincter and extending up the recta1 waI1, had spread from this IocaI focus into a
* Read before the New York ProctoIogicaI Society, February 2, 445
1939.
446
* me&an
Journal
of Surgery
Schapiro-Recta1
ThrombophIebitis
FEBRUARY, rgqr
f. Ei?TEERAL ART SUBCLAV ART.
I. 2. 3, 4. ’ 5. 6.
.‘-.;.,:
_ THROMBOPHLEBITIS. PULMONARY EhjBOLUS. CEREBRAL EMBOLUS. PATENT FORAMEN WALE. ~ PATENT DUCT ART INT. VENTRICULAR DEFEC’I:
--SUPERIOR
%IDDLE
HEM. VEIN
HEM. VEIN
s’
FIG. I. Schematic drawing illustrating the various pathways of emboli from the veins of the rectum. The arrows indicate the course taken by a rectal emboIus (I) through the inferior vena cava into the right heart and pulmonary artery into the lung, (2) eventuaIly absorbed here by the venous capillaries and passed into the pulmonary vein, thence through the left heart into the aorta and then to the brain or (3) other arterial branches. The “paradoxica1 embolism” is made possibIe when there is present either (4) patent foramen ovaIe, (5) patent ductus arteriosus, or (6) interventricular defect.
NEW
SERVESVOL. LI, No.
z
Schapiro-Recta1
systemic infection, with possible numerous small emboli Iodged in the cerebrum. The high temperature, the profound prostration, the cerebra1 drowsiness and rapid pulse a11 indicated a grave prognosis. SuIfaniIamide, gr. IO, every three hours was immediateIy started. Improvement was noted late the next afternoon. The patient recovered from his drowsiness and was mentaIIy alert. The temperature dropped from 104 to IO~F., but toward evening, the patient again became irrational and complained of a severe headache. Recta1 examination at this time showed that posterior to and to the left of the thrombosed area previousIy described, there was a prominent, boggy sweIIing merging with the former mass. This was considered a rectal abscess. During the night, the abscess apparentIy perforated and six loose stools were passed. The temperature subsided to IOIF. and the rectal mass was considerably reduced in size. For the next three days steady improvement occurred aIthough the facia1 paresis, headache, and periods of disorientation persisted. The temperature decIined toward normal, and the blood culture at this time was steriIe. Accordingly, the dosage of sulfanilamide was reduced from 80 to 40 gr. daily. On the eIeventh day of illness, the patient’s condition was definiteIy better in spite of the persistence of headache and drowsiness. The recta1 mass had compIeteIy disappeared and there was no pain in the area. On discharge from the hospital on the seventeenth day, he was symptom-free but the right facia1 weakness and hyperactive reflexes remained. A neuroIogic examination, thirteen months later reveaIed the gait and station steady, the coFrdination intact, the sense of smeI1 and taste norma and the vision good. There was no nystagmus or diplopia. A definite overactivity of the Ieft side of the face was noted on speaking, whiIe the right side drooped. The tongue deviated to the Ieft. Deep reflexes were present, the right side much more active than the Ieft. An equivoca1 Babinski was present on the right side. COMMENT
Thrombosis of the inferior hemorrhoida vein is seen reguIarIy whereas in’volvement of the superior hemorrhoidal plexus is comparativeIy infrequent.* Fortunately,
ThrombophIebitis
American ~~~~~~~ of surgery
447
thrombophIebitis is not often a compIication of thrombosis in this region. When it does occur, infected emboIi may be disseminated.4 EmboIi from the hemorrhoidal veins usually terminate in the puImonary vesseIs. (Fig. I .) However, Boydg states, “ It occasionaIIy happens that an emboIus arising in a vein Iodges in an artery other than the puImonary artery. Such an emboIus must therefore have reached the Ieft side of the heart, aIthough carried by the veins to the right side. This occurrence, known as paradoxica1 emboIism, has aIways been more or Iess of a puzzle. The most important exampIe is afforded by puerpera1 hemipIegia. The usual expIanation given is that the embolus has passed through a patent foramen 0vaIe.” Rostan,” in a study of 71 I autopsies, found 139 with patent foramen ovale, of which seven cases had paradoxica1 embolism, three being cerebraI. Rabinowitz et aI.‘O coIIected eIeven cases of cerebral emboIus in congenita1 heart disease. NevertheIess, it does not seem plausible to expIain every case of cerebra1 emboIus on the basis of a congenita1 heart. Many of these cases may be instances of thrombophlebitis of a cerebra1 vesse1 due to clumps of bacteria having passed through the rather wide puImonary capiIIaries.4 Necropsy in cases of puerpera1 hemipIegiag has shown a secondary endocarditis on the left side of the heart, the vegetations having formed the source of the cerebra1 emboIi. FinaIIy infarction of the Iung may be foIIowed by thrombosis of the puImonary veins, which in turn may be responsibIe for emboIic phenomena in the cerebra1 circuIation. AIthough puImonary embolism foIlowing recta1 pathoIogy is not uncommon, serious resuIts are found in comparatively few cases. The doubIe bIood suppIy to the Iung coming from the bronchial and puImonary arteries (-Fig. I) tends to prevent infarct formation. Newman7 reported five cases of puImonary embolism folIowing hemorrhoidectomy, one foIIowing the injection of quinine and urea, and one case folIowing
448
American
Journal
of Surgery
Schapiro-Recta1
sigmoidoscopy. Cain8 and SzanceP aIso noted pulmonary emboIism as a compIication of thrombophlebitis of the hemorrhoida pIexus. However, cerebra1 emboIism foIIowing recta1 disease is extremeIy rare. A very carefu1 search of the Iiterature reveaIed but one substantiated by autopsy reported by Ohm6 in IgoT. His patient had a thrombophIebitis of the hemorrhoida pIexus which gave rise to repeated cerebral emboli. The patient died and post-mortem examination reveaIed a patent foramen 0vaIe. Newman’s patient deveIoped a hemipIegia immediateIy after a simpIe ana fistuIectomy. SUMMARY I. A case of thrombophIebitis of the superior hemorrhoidal venous plexus followed by a Streptococcus hemolyticus septicemia and cerebra1 emboli is presented. 2. It is our opinion that emboIi from the infected thrombus in the rectum Iodged in the Iungs, fltered through the wide puImonary capiIIaries and passed into the arteria1 circuIation of the brain. The absence of apparent endocardia1 changes and signs of a congenita1 heart Iesion tend to support this view.
ThrombophIebitis 3. Rapid and spectacuIar recovery forIowed the administration of Iarge doses of suIfaniIamide. 4. As far as can be determined this is the first case of its kind on record. REFERENCES I. ABBOTT, M. E., LEWIS, D. S., and BEATTIE, W. W.
Cerebral embolism, differential study of pulmonary stenosis and pulmonary atresia of developmental origin, and death from paradoxical cerebral embolism in 3 cases. Am. J. M. SC., 165 : 636, 1923. 2. THOMPSON, T., and EVANS, W. Paradoxical embolism. Quart. .I. Med., 23: 135, 1930. 3. HIRSCHBOECK, F. J. Paradoxical embolism with patent foramen ovale. Am. J. M. SC., 189: 236, 1935. 4. DACOSTA, J. C. Modern Surgery. Philadelphia, 1920. W. B. Saunders Company. 5. ROSTAN, A. Contribution B [‘etude de l’embolie croisee consecutive a la persistence du trou de batal. These de Genke, 1884. 6. OHM, J. Klinische Beobachtungen bei offenem Foramen Ovale deren diagnostischen und Bedeutung. Ztscbr. f. klin. Med., 61: 374, 1907. 7. NEWMAN, S. E. Thrombosis and embolism. Am. Proct. Sot., p. 23. 1931. 8. CAIN, A. Suprahemorrhoidal thrombophlebitis of rectum. Pratt. Med., 17: 202, 1936. g. BOYD, WILLIAM. Surgical Pathology. Philadelphia, 1929. W. B. Saunders Company. IO. RABINOWITZ,M. A., WEINSTEIN, J., and MARCUS. Paradoxical brain abscess in congenital heart disease. Am. Heart J., 7: 790, 1932. I I. SZANCER,H., and ZIELINSKI, T. Thrombophlebitis of hemorrhoidal pIexus with embolism of pulmonary artery. Polska gaz. lok., 6: I I, 1927.