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Neck mass: How would you treat?
t
figure 1 figure 2
Thrombosed veins Collateral circulation
CT image with IV contrast of the base of the neck showing This 3D reconstruction of CT images shows the ex-
thrombosed veins. tensive collateral circulation on the left, compared
with the right.
Family
Practice
Q: How do you fit together this constellation of findings: septic neck vein thromboses, fever
(albeit low-grade), and leukocytosis in an
immunocompromised patient with history of DVT, recent pharyngitis, and recent central
venous access port removal?
A:
You vaguely recall that jugu- You realize that most patients with
lar thrombophlebitis is associated suppurative thrombophlebitis present
with some syndrome, so you turn to in a much more toxic state than yours
UpToDate and do a search on “jugular did. Perhaps you caught it early. She
thrombophlebitis.” certainly has risk factors, including her
There you learn that Lemierre’s recent pharyngitis and central venous
syndrome, also known as necrobacil- catheterization. The prominent collater-
losis, is septic thrombophlebitis of the al circulation raises the possibility that
jugular vein. It most commonly devel- this may have developed subacutely, fol-
ops following pharyngitis, and has been lowing a more indolent course than is
associated with dental microbes.1,2 generally reported.
Similar syndromes of suppurative The organisms responsible for sup-
thrombophlebitis may also occur in purative thrombophlebitis depend on
peripheral veins, associated with intra- the infection’s site of origin. Most of the
venous catheterization (especially PICC time in the peripheral veins or vena cava,
lines3), the superior and inferior vena Staphylococcus, a member of normal
cava, always associated with central skin flora, is the pathogen. Streptococ-
lines,4 and the ovarian veins.5 cus, Enterobacteriaceae, Candida, and
fast track even cytomegalovirus have been docu-
THE CASE: mented.4,7,8 Jugular septic thrombophle-
z You caught it early bitis draws from the oral flora, with the
You can see Suppurative thrombophlebitis. This most common causative agent being the
thrombosed veins problem often presents with fever and anaerobic Fusobacterium.
on the CT but rigorous chills. Swelling and tenderness is A thrombus provides an excellent
noted over the affected vein in about half source of nutrients for the microbes,
nothing suggestive the cases. Obviously, though, inspection which colonize it and establish what is
of pulmonary and palpation of the vena cava is chal- essentially a biofilm. These complex mi-
or septic emboli lenging and such signs do not apply when crobial architectures are extraordinarily
these vessels are involved. resistant to antibiotic therapy, especially
Respiratory distress due to septic when compared with plantonic bacteria.9
pulmonary emboli and secondary pneu- Not only does the thrombus facilitate
monia is common. Metastatic abscess the infection, but the bacteria facilitate
formation at other sites, such as joint and thrombus formation by promoting plate-
bone, have been reported.1,6 let aggregation.10
t
Central venous access: Ensuring proper care
Family
Practice
Family Practice Perspective: Beware these complications
warfarin, more down, she’s adequately anticoagulated, 6. Pruitt BA Jr, McManus WF, Kim SH, Treat RC.
has been afebrile for 48 hours, and is Diagnosis and treatment of cannula-related intra-
for her history extremely eager to go home.
venous sepsis in burn patients. Ann Surg 1980;
191:546–554.
of DVT than for She is discharged with a prescrip- 7. Baker CC, Petersen SR, Sheldon GF. Septic
the management tion of amoxicillin/clavulanate 3 times phlebitis: a neglected disease. Am J Surg 1979;
138:97–103.
of suppurative daily for 4 weeks, as the literature sug-
gests that most Fusobacterium are sen- 8. Peterson P, Stahl-Bayliss CM. Cytomegalovirus
thrombophlebitis sitive to this agent.11 She is instructed
thrombophlebitis after successful DHPG therapy
[letter]. Ann Intern Med 1987; 106:632–633.
to return if any recurrent fevers, chest 9. Parsek MR, Singh PK. Bacterial biofilms: an
pain, or respiratory symptoms develop. emerging link to disease pathogenesis. Ann Rev
At a routine follow-up appointment in Microbiol 2003; 57:677–701.
a month, she remains asymptomatic. n 10. Forrester LJ, Campbell BJ, Berg JN, Barrett JT.
Aggregation of platelets by Fusobacterium nec-
rophorum. J Clin Micro 1985; 22:245–249.
11. Kuriyama T, Karasawa T, Nakagawa K, Yamamo-
re f e re n c e s to E, Nakamura S. Incidence of beta-lactamase
1. Sinave CP, Hardy GJ, Fardy PW. The Lemierre production and antimicrobial susceptibility of
Syndrome: suppurative thrombophlebitis of the anaerobic gram-negative rods isolated from pus
internal jugular vein secondary to oropharyngeal specimens of orofacial odontogenic infections.
infection. Medicine (Baltimore) 1989; 68:85–94. Oral Microbiol Immunol 2001; 16:10–15.