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A Case of Septic Superficial Thrombophlebitis of Varicose Veins Associated with Yersinia enterocolitica and Propionibacterium
EJVES Extra 24 (2012) e16ee17
Contents lists available at SciVerse ScienceDirect
EJVES Extra journal homepage: www.ejvesextra.com
Short Report
A Case of Septic Superficial Thrombophlebitis of Varicose Veins Associated with Yersinia enterocolitica and Propionibacterium K. Kam Fai Ho a, *, A. Al-Timimi a, d, P.J. Walker a, b, c a
University of Queensland School of Medicine, Australia Discipline of Surgery, Australia c Centre for Clinical Research, Australia d Nambour General Hospital, Australia b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 April 2012 Accepted 21 June 2012
A patient with a history of varicose veins developed septic superficial thrombophlebitis in the great saphenous vein (GSV). Blood cultures grew Yersinia enterocolitica and Propionibacterium. Ultrasonography showed thrombus extending into the deep venous system, which exposed the patient to the risk of septic emboli. This risk, together with the contraindication to anticoagulation due to the patient’s gastric erosions and ulceration, prompted the decision to surgically remove the thrombus. Although superficial thrombophlebitis is common in the setting of varicose veins, septic superficial thrombophlebitis is rare, especially due to Yersinia infection. Ó 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Thrombophlebitis Septic Varicose veins Yersinia Suppurative Bacteraemia
A previously well 72 old man with a long history of varicose veins presented after one week of flu-like symptoms associated with a productive cough and the development of a painful swollen right leg and systemic symptoms including fever (38.5 C), chills and rigors. His local doctor had commenced him on oseltamivir (TamifluÒ) for a suspected diagnosis of influenza and following this he developed nausea, vomiting and diarrhoea. On examination, his right leg was erythematous with tenderness and induration along the course of the great saphenous vein (GSV). There was also associated pitting oedema at the ankle. Ultrasonography confirmed superficial thrombophlebitis (STP) of the GSV with thrombus extending to the saphenofemoral junction (SFJ) but not into the common femoral vein (CFV). He was initially treated empirically with flucoxicillin and gentamicin for STP with associated fever. Blood cultures subsequently grew Yersinia enterocolitica and his treatment was changed to oral ciprofloxacin and intravenous gentamicin and subsequently to ceftriaxone. There was no obvious source of Yersinia infection. Chest X-ray and abdominal ultrasound were unremarkable. The patient was also given prophylactic subcutaneous enoxaparin 40 mg daily.
* Corresponding author. K. Kam Fai Ho, 57 Hollywood Street, Runcorn, Brisbane QLD 4113, Australia. Tel.: þ61 0415483856. E-mail address: [email protected] (K. Kam Fai Ho).
Despite antibiotic therapy, the patient remained febrile and the swelling of the right leg worsened over the next three days. Small fluctuant discharging areas with localized skin breakdown were found along the course of the right GSV (Fig. 1). Aspirate of fluid from collections in the leg also grew Y. enterocolitica. Repeat ultrasonography revealed that the thrombus had extended further, with a 3.5 cm tongue of thrombus extending into but not occluding the CFV. Therapeutic enoxaparin was commenced but the patient subsequently developed haematemesis associated with a fall in haemoglobin from 138 g/L on admission to 104 g/L. Enoxaparin was discontinued. Oesophago-gastro-duodenoscopy identified severe distal oesophagitis, prepyloric erosions and a duodenal ulcer with a visible vessel which was clipped. The patient then underwent surgery where all GSV tributaries were ligated and the thrombus protruding into the CFV was removed through the SFJ, under vision, after proximal and distal clamping of the CFV. After flushing the SFJ was suture ligated. Multiple incisions were made to evacuate the purulent STP, excise the GSV and its tributaries segmentally and debride adjacent compromised tissue. Cultures of the excised GSV and STP grew Y. enterocolitica and Propionibacterium. A heparin infusion was maintained for the first 24 h post-operatively and then ceased. The patient was afebrile the next day and there was progressive improvement in his general condition, mobility, leg swelling and wound healing (Fig. 2). He regained full mobility prior
1533-3167/$ e see front matter Ó 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvsextra.2012.06.004
K. Kam Fai Ho et al. / EJVES Extra 24 (2012) e16ee17
Figure 1. Septic superficial thrombophlebitis causing skin lesions at the medial right lower limb.
Figure 2. Medial right lower limb after removal of thrombus and debridement.
to discharge. At the post-operative follow-up two months later, the wounds were almost completely healed and the patient continued follow-up with his general practitioner. STP may occur in normal veins but more commonly occurs in varicose veins.1 Septic STP in lower extremity varicose veins is rare. Septic thrombophlebitis should be suspected when erythema extends significantly beyond the margin of the vein and if there is significant fever. Most septic STP nowadays occurs in the hospital setting in association with intravenous catheters and peripherally inserted central catheters and ports.2 In catheter related septic STP the most common infective microorganism is Staphylococcus aureus. Streptococci, Enterobacteriae and Candida infections are also commonly seen. It is also hypothesized that septic STP can arise from seeding of enteric microbes after bacteraemia.3 There are few
e17
reports of septic STP associated with varicose veins. Navarro reported a case of fatal septic thrombophlebitis in a patient with metastatic gastric adenocarcinoma who developed a septic focus in a varicose GSV. Salmonella enteritidis was cultured from a thrombus removed from the varicosity.4 Salamon reported a case of septic STP in a varicose GSV caused by Salmonella panama, which resulted in bilateral pulmonary embolism.5 We are not aware of any reports of septic STP or DVT associated with Y. enterocolitica or Propionibacterium. In humans, Y. enterocolitica is transmitted orally through contaminated water or food, especially in pork products. It commonly leads to gastrointestinal infections such as enteritis, acute mesenteric lymphadenitis and terminal ileitis.6 Bacteraemia can occur in the setting of immunosuppression, which may be followed by metastatic spread of the bacteria to extraintestinal sites such as abscesses of the liver, kidney and spleen, pneumonia, meningitis or endocarditis. The propionibacteria are commensal on skin and other keratinized epithelia. In the current case, there was no clearly documented source of the Yersinia infection or predisposing factors to Yersinia bacteraemia, although the nausea, vomiting and diarrhoea that were attributed to the oseltamivir (TamifluÒ) may have been related to Yersinia infection. The Propionibacterium cultured from the operative specimens was likely a commensal rather than the primary infecting organism. Management of septic STP includes removing the source of infection and antibiotics to treat the infecting organisms. In this case the presence of thrombus extending into the deep venous system exposed the patient to the risk of septic emboli. This risk, together with the contraindication to anticoagulation due to the patient’s gastric erosions and ulceration, prompted the decision to surgically remove the thrombus from the CFV and at the same time ligate the SFJ and incise, drain and debride the collections in the limb. The patient’s rapid improvement after surgery was likely due to the combination of surgical intervention and antibiotic treatment. References 1 Decousus H, Epinat M, Guillot K, Quenet S, Boissier C, Tardy B. Superficial vein thrombosis: risk factors, diagnosis, and treatment. Curr Opin Pulm Med 2003;9:393e7. 2 Baker CC, Petersen SR, Sheldon GF. Septic phlebitis e neglected disease. Am J Surg 1979;138:97e103. 3 Khan EA, Correa AG, Baker CJ. Suppurative thrombophlebitis in children: a tenyear experience. Pediatr Infect Dis J 1997;16:63e7. 4 Navarro M, Almirante B, Bellmunt J, Jolis L. Fatal septic thrombophlebitis due to Salmonella enteritidis. Eur J Clin Microbiol Infect Dis 1989;8:82e3. 5 Salamon SA, Prag J. A case of superficial septic thrombophlebitis in a varicose vein caused by Salmonella panama. Clin Microbiol Infect 2001;7:34e6. 6 Bottone EJ. Yersinia enterocolitica: overview and epidemiologic correlates. Microbes Infect 1999;1:323e33.
Contents lists available at SciVerse ScienceDirect
EJVES Extra journal homepage: www.ejvesextra.com
Short Report
A Case of Septic Superficial Thrombophlebitis of Varicose Veins Associated with Yersinia enterocolitica and Propionibacterium K. Kam Fai Ho a, *, A. Al-Timimi a, d, P.J. Walker a, b, c a
University of Queensland School of Medicine, Australia Discipline of Surgery, Australia c Centre for Clinical Research, Australia d Nambour General Hospital, Australia b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 April 2012 Accepted 21 June 2012
A patient with a history of varicose veins developed septic superficial thrombophlebitis in the great saphenous vein (GSV). Blood cultures grew Yersinia enterocolitica and Propionibacterium. Ultrasonography showed thrombus extending into the deep venous system, which exposed the patient to the risk of septic emboli. This risk, together with the contraindication to anticoagulation due to the patient’s gastric erosions and ulceration, prompted the decision to surgically remove the thrombus. Although superficial thrombophlebitis is common in the setting of varicose veins, septic superficial thrombophlebitis is rare, especially due to Yersinia infection. Ó 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Thrombophlebitis Septic Varicose veins Yersinia Suppurative Bacteraemia
A previously well 72 old man with a long history of varicose veins presented after one week of flu-like symptoms associated with a productive cough and the development of a painful swollen right leg and systemic symptoms including fever (38.5 C), chills and rigors. His local doctor had commenced him on oseltamivir (TamifluÒ) for a suspected diagnosis of influenza and following this he developed nausea, vomiting and diarrhoea. On examination, his right leg was erythematous with tenderness and induration along the course of the great saphenous vein (GSV). There was also associated pitting oedema at the ankle. Ultrasonography confirmed superficial thrombophlebitis (STP) of the GSV with thrombus extending to the saphenofemoral junction (SFJ) but not into the common femoral vein (CFV). He was initially treated empirically with flucoxicillin and gentamicin for STP with associated fever. Blood cultures subsequently grew Yersinia enterocolitica and his treatment was changed to oral ciprofloxacin and intravenous gentamicin and subsequently to ceftriaxone. There was no obvious source of Yersinia infection. Chest X-ray and abdominal ultrasound were unremarkable. The patient was also given prophylactic subcutaneous enoxaparin 40 mg daily.
* Corresponding author. K. Kam Fai Ho, 57 Hollywood Street, Runcorn, Brisbane QLD 4113, Australia. Tel.: þ61 0415483856. E-mail address: [email protected] (K. Kam Fai Ho).
Despite antibiotic therapy, the patient remained febrile and the swelling of the right leg worsened over the next three days. Small fluctuant discharging areas with localized skin breakdown were found along the course of the right GSV (Fig. 1). Aspirate of fluid from collections in the leg also grew Y. enterocolitica. Repeat ultrasonography revealed that the thrombus had extended further, with a 3.5 cm tongue of thrombus extending into but not occluding the CFV. Therapeutic enoxaparin was commenced but the patient subsequently developed haematemesis associated with a fall in haemoglobin from 138 g/L on admission to 104 g/L. Enoxaparin was discontinued. Oesophago-gastro-duodenoscopy identified severe distal oesophagitis, prepyloric erosions and a duodenal ulcer with a visible vessel which was clipped. The patient then underwent surgery where all GSV tributaries were ligated and the thrombus protruding into the CFV was removed through the SFJ, under vision, after proximal and distal clamping of the CFV. After flushing the SFJ was suture ligated. Multiple incisions were made to evacuate the purulent STP, excise the GSV and its tributaries segmentally and debride adjacent compromised tissue. Cultures of the excised GSV and STP grew Y. enterocolitica and Propionibacterium. A heparin infusion was maintained for the first 24 h post-operatively and then ceased. The patient was afebrile the next day and there was progressive improvement in his general condition, mobility, leg swelling and wound healing (Fig. 2). He regained full mobility prior
1533-3167/$ e see front matter Ó 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvsextra.2012.06.004
K. Kam Fai Ho et al. / EJVES Extra 24 (2012) e16ee17
Figure 1. Septic superficial thrombophlebitis causing skin lesions at the medial right lower limb.
Figure 2. Medial right lower limb after removal of thrombus and debridement.
to discharge. At the post-operative follow-up two months later, the wounds were almost completely healed and the patient continued follow-up with his general practitioner. STP may occur in normal veins but more commonly occurs in varicose veins.1 Septic STP in lower extremity varicose veins is rare. Septic thrombophlebitis should be suspected when erythema extends significantly beyond the margin of the vein and if there is significant fever. Most septic STP nowadays occurs in the hospital setting in association with intravenous catheters and peripherally inserted central catheters and ports.2 In catheter related septic STP the most common infective microorganism is Staphylococcus aureus. Streptococci, Enterobacteriae and Candida infections are also commonly seen. It is also hypothesized that septic STP can arise from seeding of enteric microbes after bacteraemia.3 There are few
e17
reports of septic STP associated with varicose veins. Navarro reported a case of fatal septic thrombophlebitis in a patient with metastatic gastric adenocarcinoma who developed a septic focus in a varicose GSV. Salmonella enteritidis was cultured from a thrombus removed from the varicosity.4 Salamon reported a case of septic STP in a varicose GSV caused by Salmonella panama, which resulted in bilateral pulmonary embolism.5 We are not aware of any reports of septic STP or DVT associated with Y. enterocolitica or Propionibacterium. In humans, Y. enterocolitica is transmitted orally through contaminated water or food, especially in pork products. It commonly leads to gastrointestinal infections such as enteritis, acute mesenteric lymphadenitis and terminal ileitis.6 Bacteraemia can occur in the setting of immunosuppression, which may be followed by metastatic spread of the bacteria to extraintestinal sites such as abscesses of the liver, kidney and spleen, pneumonia, meningitis or endocarditis. The propionibacteria are commensal on skin and other keratinized epithelia. In the current case, there was no clearly documented source of the Yersinia infection or predisposing factors to Yersinia bacteraemia, although the nausea, vomiting and diarrhoea that were attributed to the oseltamivir (TamifluÒ) may have been related to Yersinia infection. The Propionibacterium cultured from the operative specimens was likely a commensal rather than the primary infecting organism. Management of septic STP includes removing the source of infection and antibiotics to treat the infecting organisms. In this case the presence of thrombus extending into the deep venous system exposed the patient to the risk of septic emboli. This risk, together with the contraindication to anticoagulation due to the patient’s gastric erosions and ulceration, prompted the decision to surgically remove the thrombus from the CFV and at the same time ligate the SFJ and incise, drain and debride the collections in the limb. The patient’s rapid improvement after surgery was likely due to the combination of surgical intervention and antibiotic treatment. References 1 Decousus H, Epinat M, Guillot K, Quenet S, Boissier C, Tardy B. Superficial vein thrombosis: risk factors, diagnosis, and treatment. Curr Opin Pulm Med 2003;9:393e7. 2 Baker CC, Petersen SR, Sheldon GF. Septic phlebitis e neglected disease. Am J Surg 1979;138:97e103. 3 Khan EA, Correa AG, Baker CJ. Suppurative thrombophlebitis in children: a tenyear experience. Pediatr Infect Dis J 1997;16:63e7. 4 Navarro M, Almirante B, Bellmunt J, Jolis L. Fatal septic thrombophlebitis due to Salmonella enteritidis. Eur J Clin Microbiol Infect Dis 1989;8:82e3. 5 Salamon SA, Prag J. A case of superficial septic thrombophlebitis in a varicose vein caused by Salmonella panama. Clin Microbiol Infect 2001;7:34e6. 6 Bottone EJ. Yersinia enterocolitica: overview and epidemiologic correlates. Microbes Infect 1999;1:323e33.