Septic Thrombophlebitis

Abstract

Septic thrombophlebitis, as a result of invasion from adjacent nonvascular infections, includes conditions such as Lemierre syndrome (internal jugular vein septic thrombophlebitis), pylephlebitis (portal vein septic thrombophlebitis), and septic thrombophlebitis of the dural sinuses and the pelvic veins. All of these conditions are associated with a very high mortality if untreated. Appropriate antibacterial therapy dramatically improves the outcome of these infections and results in a low mortality rate, with the notable exception of septic thrombophlebitis of the dural sinuses. The endovascular nature of these infections results in secondary metastatic disease, including pneumonia, endocarditis, and arthritis due to septic embolization and/or hematogenous bacterial spread. The appropriate diagnosis and management of these infections depends on a high degree of clinical suspicion, the use of imaging studies, and early initiation of empiric antibacterial therapy. In this article, we review the diagnosis and management of septic thrombophlebitis, focusing on Lemierre syndrome, pylephlebitis, and septic thrombophlebitis of the pelvic veins.

Pylephlebitis in a Previously Healthy Emergency Department Patient with Appendicitis

“…While diverticulitis is thought to be the leading cause of this disease, it has also been described in appendicitis, cholecystitis, hemorrhoidal disease, necrotizing pancreatitis, and various other suppurative intra-abdominal infections 1. The disease was first described by Waller in 1846 as a source of pyogenic intrahepatic abscesses 2.…”

“…Fever is the most common presenting symptom, followed by abdominal pain, which is often vague and poorly localized 1,2. Nausea, vomiting, scleral icterus and a tender, enlarged liver may also be present in some cases, especially in those complicated by liver abscesses 1,4.…”

“…Fever is the most common presenting symptom, followed by abdominal pain, which is often vague and poorly localized 1,2. Nausea, vomiting, scleral icterus and a tender, enlarged liver may also be present in some cases, especially in those complicated by liver abscesses 1,4. In approximately 80% of patients, blood cultures will be positive, with the most common organism being Bacteroides fragilis , followed by E. Coli and Steptococcus sp 1,2,4.…”

“…Nausea, vomiting, scleral icterus and a tender, enlarged liver may also be present in some cases, especially in those complicated by liver abscesses 1,4. In approximately 80% of patients, blood cultures will be positive, with the most common organism being Bacteroides fragilis , followed by E. Coli and Steptococcus sp 1,2,4. Liver function tests may be abnormal in some cases, but are generally normal.…”

“…Many patients will present in a distressed state, with approximately 20% presenting in sepsis 1. Fluid resuscitation, broad-spectrum antibiotics and eradication of the suppurative source are the mainstays of treatment.…”