The Pivotal Role of Deep Vein Thrombophlebitis in the Development of Acute Disseminated Staphylococcal Disease in Children

Abstract

ABSTRACT. Deep vein thrombophlebitis (DVT) and septic pulmonary emboli (PE) are rare in children. The association of DVT and acute disseminated staphylococcal disease (DSD) during childhood has not been previously reported. We report 3 children who developed a triad of DVT, septic PE, and acute osteomyelitis with Staphylococcus aureus cultured from blood and bone. One child succumbed, while 2 survived following prolonged, morbid hospitalizations. The rapid clinical deterioration observed in these patients might be caused by the aggressiveness of staphylococcal infection combined with an ongoing showering of septic emboli from the ileo-femoral DVT. We suggest that infected DVT with septic PE had a pivotal role in the development of DSD in these children. The presence of this triad should prompt aggressive treatment with the appropriate antibiotics, anticoagulation, surgical drainage, and assisted ventilation when indicated. Pediatrics 2000;106(6). URL: http://www.pediatrics.org/cgi/content/full/106/6/e87; deep vein thrombophlebitis, disseminated staphylococcal disease, osteomyelitis, pediatric, septic pulmonary emboli.ABBREVIATIONS. DVT, deep vein thrombophlebitis; PE, pulmonary emboli; DSD, disseminated staphylococcal disease; WBC, white blood cell count. D eep vein thrombophlebitis (DVT) and septic pulmonary emboli (PE) rarely occur in children. The triad of DVT, septic pulmonary embolism, and acute osteomyelitis in children has not been emphasized in the literature or in any report of acute disseminated staphylococcal disease (DSD) in childhood. [1][2][3][4][5][6] The present report describes 3 children with this triad, 1 of whom died, while 2 survived after prolonged, complicated hospitalizations. Theories regarding the role of DVT in the development of DSD, diagnostic modalities, and appropriate therapies are discussed. CASE REPORTS Patient 1An 11-year-old previously healthy boy presented with left hip pain, fever (approaching 39.7°C), recurrent vomiting, and a generalized erythematous rash of 2 days duration. Physical examination showed an alert child: temperature, 39°C; heart rate, 188 beats/minute; respiratory rate, 32 breaths/minute; and blood pressure, 75/50 mm Hg. A diffuse erythematous rash was present over the extremities. Chest examination revealed crepitations over the left side. The left hip joint was tender with no evidence of local infection.Initial laboratory results included: hemoglobin, 12.6 g/dL; white blood cell count (WBC), 28 000/mm 3 with 80% polymorphonuclears; platelet count, 168 000/mm 3 ; prothrombin time, 24% (international normalized ratio: 2.2); and partial thromboplastin time, 42.8 seconds. The chest radiograph showed bilateral diffuse infiltrates (Fig 1). Ultrasonography of the left hip joint demonstrated intraarticular fluid and thickening of the joint capsule. A bone scan was consistent with osteomyelitis of the left proximal femur. Doppler ultrasound revealed thrombosis with partial occlusion of the left femoral vein (Fig 2). Blood cultures were drawn and intravenous administ...

Staphylococcus aureus septicemia presenting as disseminated intravascular coagulation - thrombotic thrombocytopenic purpura overlap and thrombus in inferior vena cava, right atrium and right ventricle: a case report

“…In most cases involving an infected right atrial thrombus, aggressive treatment is mandatory. Staphylococcus aureus septicemia has been associated with DVT, [20][21][22] the maximum risk seems to be with osteomyelitis. 22 Staphylococci release alpha toxin and coagulase; the former leads to platelet aggregation and spasm of smooth muscle while the latter promotes clot formation due to interaction with fibrinogen.…”

“…Staphylococcus aureus septicemia has been associated with DVT, [20][21][22] the maximum risk seems to be with osteomyelitis. 22 Staphylococci release alpha toxin and coagulase; the former leads to platelet aggregation and spasm of smooth muscle while the latter promotes clot formation due to interaction with fibrinogen. In some patients, an acute infection related prothrombotic state 20 was evident in the form of antiphospholipid antibodies and elevated factor VIII levels which did not persist on follow up.…”

A case of sudden death due to septic pulmonary embolism

“…Furthermore, acute disseminated bacterial disease is a reported complication of acute osteomyelitis complicating deep vein thrombosis and septic thrombophlebitis and septic pulmonary embolism. [7] The sudden deterioration of her condition can be explained by the aggressiveness of infection combined with an ongoing showering of septic emboli from the deep venous thrombosis. The embolic blood clot that leads to an infarction in the pulmonary vasculature also contains microorganisms that provoke a focal abscess.…”

Septic Intramuscular Embolism in a Neutropenic Patient with Myelodysplastic Syndrome Accompanied by Asymptomatic Septic Pulmonary Emboli

“…Alfa-toxin acts on cell membranes and may produce an aggregation of platelets and smooth muscle spasm (5). A variety of enzymes are released, among them coagulase, which specifically interacts with fibrinogen and causes plasma to clot.…”