Lesson of the month 1: Spontaneous septic thrombophlebitis presenting with bacteraemia diagnosed by PET-CT scan

Abstract

Spontaneous septic thrombophlebitis is a rare complication of Staphylococcus aureus bacteraemia. Its true incidence is unknown as septic thrombus is not often considered as a source in the typical 'screen' of tests used to fi nd the source of a bacteraemia. Positron emission tomography computerised tomography (PET-CT) is becoming increasingly available to physicians, is highly sensitive and yields specifi c anatomical information regarding abnormal metabolically active sites in infection, infl ammation and neoplasia. In this case, PET-CT enabled the identification of the source of a septic thrombus and enabled focused management. PET-CT should be considered as part of the raft of tests used to identify an obscure source of fever/bacteraemia. KEYWORDS : PET-CT , septic thrombophlebitis , Staphylococcus aureus Case historyA 58-year-old Caucasian man presented to his primary care doctor following a 5-day febrile illness with lower back and leg pain. There was no weight loss or recent foreign travel. The patient had experienced episodes of uncontrolled intermittent shivering or rigors. He was referred to the emergency medical team for further evaluation.Vital signs, including pulse, were normal on admission. Subsequent observations demonstrated an intermittent fever, which peaked at 38.2°C and was accompanied by a pulse of 110 bpm.Physical examination showed normal heart sounds, normal abdominal findings and no sign of peripheral oedema. Breath sounds and oxygen saturations were normal. There were no splinter haemorrhages. Urine was positive for protein (trace) and negative for blood cells.Preliminary blood tests showed an elevated white cell count 15.3×10 9 /L and a C-reactive protein (CRP) of 421 mg/L (normal <5). The patient was admitted and treated with intravenous amoxicillin and clavulanic acid. Blood cultures taken at presentation yielded a strong growth of Staphylococcus aureus on the second day of admission. The isolates were sensitive to flucloxacillin. ABSTRACTLesson of the month 1: Spontaneous septic thrombophlebitis presenting with bacteraemia diagnosed by PET-CT scan Differential diagnoses considered included endocarditis, bacterial discitis, psoas abscess and other occult staphylococcal abscess. The patient underwent a number of preliminary investigations: a chest X-ray, computerised tomography (CT) urinary tract, magnetic resonance imaging (MRI) spine and transoesophageal echo, which were all within normal limits. MRI spine demonstrated degenerative changes. Appearances were not consistent with a diagnosis of discitis. A transthoracic echocardiogram was normal.Antibiotics were changed to intravenous flucloxacillin. A reduction in CRP to normal and resolution of fever occurred over the next 5 days. A whole-body fluorodeoxyglucose (FDG) positron emission tomography (PET) CT scan was obtained.Abnormal uptake was demonstrated in an area corresponding to the femoral vein with no other areas of abnormal avidity (Fig 1 ).Ultrasound scanning of the vein demonstrated occlusive thrombus. No distal swelling of ...

Inferior vena cava thrombosis with septic shock case report and literature review

“…However, no such study has been conducted speci cally for diagnosing IVCST. In recent years, PET-CT has shown promise in the diagnosis of septic thrombophlebitis, with greater FDG uptake observed in infectious thrombosis compared to non-infectious thrombosis [12][13] . The primary treatment for septic thrombophlebitis remains antibiotics.…”