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A. Pathogenesisnavigator

  1. Usually associated with sluggish blood flow through venous sytem
  2. Intravenous lines are a major risk factor
  3. Superficial Thrombophlebitis and Deep Vein Thrombosis (DVT) [1]
    1. About 5% of patients with superficial thrombophlebitis will also have DVT
    2. More common in patients with lower extremity thrombophlebitis [2]
    3. Likely that patients with Trousseau's Syndrome have increased incidence of DVT
  4. May be associated with Bacteroides fragilis bacteremia [3]

B. Symptoms and Signs navigator

  1. Varicose Veins
  2. Pain
  3. Palpable cord
  4. Tenderness
  5. Erythema
  6. Fever
  7. May present with septic picture

C. Differential Diagnosisnavigator

  1. Lymphangitis (usually Streptococcal ssp)
  2. Cellulitis
  3. Insect Bite Reaction
  4. Hematoma
  5. DVT
  6. Thromboangiitis obliterans (Buerger's Disease)

D. Treatmentnavigator

  1. Ambulation
  2. Anti-inflammatory agents (especially aspirin, an anti-platelet agent)
  3. Graded compression stockings: prevents progression of thrombus (particularly to DVT)
  4. Septic Thrombophlebitis
    1. Usually following intravenous catheter placement, typically G+ organisms
    2. Staphylococcus aureus: oxacillin or nafcillin or cefazolin (Ancef®)
    3. Vancomycin for S. epidermidus
    4. Streptococcal ssp: penicillin (increasing resistance) or cephalosporin or nafcillin
  5. Surgery: rarely required; for removal vein after severe phlebitis
  6. Consider adding anti-coagulation with extensive superficial thrombophlebitis [4]
    1. Low Molecular Weight Heparin OR
    2. Warfarin may be used
    3. Not generally necessary, and increases costs considerably
  7. In general, warm compresses ± extremity elevation will improve superficial disease

E. Migratory Thrombophlebitis (Trousseau's Syndrome) [5] navigator

  1. Associated with cancers and vasculitides
    1. Carcinoma: pancreas, lung, ovary, testes, urinary tract, breast, stomach
    2. Vasculitis: thromboangiitis obliterans, Behcet's Disease, homocystinuria
  2. Usually difficult to treat recurrent events even with heparin or warfarin
  3. Multiple arterial thrombi leading to myocardial infarction and/or stroke may occur
  4. This represents a highly hypercoagulable state
  5. Warfarin prophylaxis is of only minimal benefit in Trousseau syndrome

F. Thrombophlebitis of Internal Jugular Vein (Lemierre's Syndrome) [6]navigator

  1. Caused by anaerobic infection in internal jugular vein
  2. Usually affects young adults, ~1 per million per year
  3. Fever, pain, swelling along angle of jaw and sternocleidomastoid muscle
  4. May present with progressive inflammation and sepsis
  5. Antibiotics with good anaerobic coverage are critical to eradication
    1. Clindamycin
    2. Carbapenems
    3. Extended range ß-lactam with ß-lactamase inhibitor
  6. Anticoagulation controversial due to possibility of spreading infection
  7. Surgical resection with internal jugular vein ligation and excision may be required

References navigator

  1. Bounameaux H and Reber-Wasem MA. 1997. Arch Intern Med. 157(16):1822 abstract
  2. Blumenberg RM, Barton E, Gelfand ML, et al. 1998. J Vasc Surg. 27(2):338 abstract
  3. Kasper DL, Sahani D, Misdraji J. 2005. NEJM. 353(7):713 (Case Record) abstract
  4. Belcaro G, Nicolaides AN, Errichi BM, et al. 1999. Angiology. 50(7):523 abstract
  5. Samuels MA, King ME, Balis U. 2002. NEJM. 347(15):1187 (Case Record) abstract
  6. Woywodt A, Merkel S, Buth W, et al. 2002. Lancet. 360(9348):1838 (Case Report) abstract