Journal of the Royal Society of Medicine Volume 83 February 1990

True spontaneous rupture of the common iliac vein

Susan Hill MBBS P J Billings MS FRCS R T Walker MS FRCS J A Dormandy FRCS Vascular Unit, St George's Hospital, Blackshaw Road, London SW17 OQT Keywords: common iliac vein; rupture

The rare previous reports of 'spontaneous' rupture ofthe iliac vein have all been associated with thrombosis or obstruction of the iliac vein. We report a case of iliac vein rupture without any apparent predisposing cause.

Case report A previously fit 52-year-old woman presented to casualty having collapsed at home. She had suddenly complained of pain in her left hip and fallen to the ground shortly after going to the lavatory. On examination she was shocked with tachycardia of 230 beats per minute and a systolic blood pressure of 50 mmHg. She had a tender non-pulsatile mass in the left iliac fossa. Both femoral pulses were present and there were no signs of venous thrombosis in the legs. Resuscitation was commenced with colloids. Over the next 20 min her systolic blood pressure rose to 100 mmHg but the left iliac fossa mass continued to enlarge. Her preoperative full blood count and urea and electrolytes were normal. She was taken to theatre where a large retroperitoneal haematoma containing dark venous blood was found in the left iliac fossa. The haematoma was explored and a 2 cm anterior longitudinal tear found in the left common iliac vein. The vein did not contain any thrombus and there was no

Septic arthritis of the hip due to bacteriodes-melanogenicus

S B Tibrewal FRCS J Kenwright MD FRCS Nuffield Orthopaedic Centre, Oxford OX3 7LD Keywords: bacteriodes-melanogenicus; hip; septic arthritis

Acute septic arthritis in adults is usually associated with poor host resistance, underlying joint diseases such as rheumatoid and osteoarthritis. Six patients with avascular necrosis of the femoral head predisposing to septic arthritis has been reported in immunosuppressed individuals'-3.

117

inflammation or venous obstruction. The laparatomy did not reveal any other abnormalities. The vein was repaired but despite vigorous resuscitation she died 4 h postoperatively. Postmortem examination was performed which showed no other cause for rupture of the vein and no thrombus was found within it. There was no evidence of any systemic disease. Histology of the vein showed no abnormality. Discussion Eight cases of iliac vein rupture have been reported unrelated to trauma. In three cases there was proximal obstruction of the iliac vein caused by compression between the common iliac artery and the sacral promontery'. Microscopic examination showed five other cases had inflammatory changes in the vessel wall associated with

thrombusl3. In two of the previous reports a rise in venous pressure may have occurred immediately before rupture. One patient with pneumonia presented after a coughing fit4 and another had bent over to pick something up6. Our patient may well have been straining during defaecation before she collapsed. We believe that this is the first reported case of true spontaneous rupture of the iliac vein. There was no obstruction ofthe iliac vein and no thrombosis found either at laparotomy or at postmortem examination. References 1 Stock SE, Gunn A. Spontaneous rupture of the iliac vein. Br J Surg 1986;73:565 2 Herrin BJ, Osborne P, Dieste A, Campbell CF. Spontaneous rupture of an iliac vein. J Vasc Surg 1975;9:182-4 3 Brown L, Sanchez F, Mannix H. Idiopathic rupture of the iliac vein. Arch Surg 1977;112:95 4 Noszczyk W, Orzeszko W. Spontaneous rupture of the iliac vein. Arch Surg 1983;118:1227 5 Elliot D, Ware CC. Spontaneous rupture of external iliac vein. J R Soc Med 1982;75:477-8

(Accepted 9 December 1988. Correspondence to Mr P J Billings)

0141-0768/90/

020117-01/$02.00/0 © 1990 The Royal Society of Medicine

The most frequent causative organism is Staphylococcus aureus. In a large number of cases no organism is recovered4 and in these it is possible that anaerobic infections are overlooked. Bacteriodes septic arthritis has not been previously reported. We report such a case associated with avascular necrosis of the femoral head in a non-immunosuppressed individual. Case report A 56-year-old man, a publican, presented with a 4-year history of symptoms typical of osteoarthritis of the left hip joint, with recent acute worsening. This was thought to be due to avascular necrosis of the femoral head (Figure 1) with probable acute effusion. He denied excessive alcohol intake. Arrangements were made for early admission for total hip replacement. On admission, clinical examination revealed a swelling of the left groin and all movements of the hip were extremely painful. At this time he had a low grade pyrexia and a diagnosis of septic arthritis was suspected.

0141-0768/90/ 020117-02/$02.00/0 © 1990 The Royal Society of Medicine

118

Journal of the Royal Society of Medicine Volume 83 February 1990

rt*z.4,{f . A. ,^.

2(a)

~~~~~~~~~~~~~~~~~~~~~~~~~~. ....

. . .t s-. ,l .

,

X ~ ~ ~ ~ ~ ~ ~ ~. .-.-. . . .

...

-..

P-P. gws.

.'.O

20-1185

Figure 1. (a) Early osteoarthritic changes9 in the left/uip. (b) Three years later there are severe osteoarthritic changes together with the appearance suggestive of avascular necrosis of the left femoral head

His total white cell count was 23 OOO/cu ml with a neutrophil count of 86%. ESR was 97 mm/h. Urine and a blood culture did not grow any organisms. No gas was seen in the joint on X-rays. The diagnosis of septic arthritis was confirmed at open operation when a large amount of foul smelling, turbid, thin pus was evacuated through an antero-lateral approach. There were multiple cloacae in the femoral head exuding the offensive pus. The femoral head was excised below the level ofthe healthy-looking neck and the acetabular cartilage was curetted. A radical excision of the capsule was performed. The joint was washed out with copious saline solution and the wound was closed over two corrugated drains. Skeleton traction was applied through an upper tibial Denham-pin. A gram stain showed gram negative bacilli and the culture disc grew bacteriodes-melanogenicus which were sensitive to metronidazole and penicillin. Subsequent wound drainage grew mixed bacteriodes and pseudomonas organisms. He was treated with metronidazole suppositories, intravenous piperacillin and gentamycin. His further progress was steady and the wound healed up in time. Investigations of immunological status and liver function did not reveal any significant abnormality. It was not possible to localize any primary focus for infection. Discussion

The symptoms of avascular necrosis and of septic arthritis ofthe hip may be similar and only a high index of suWicion may prevent the delay in diagnosis, as illustrated in the patient described. Avascular necrosis is not generally recognized as a predisposing factor to a joint infection in an otherwise healthy individual, although Martin et aL2 reported a single instance of serratia arthritis in which avascular necrosis may have been an aetiological factor. The two pathologies were associated in the patient described here (Figure 2). Although anaerobic infection of a joint is uncommon, the possibility should be borne in mind, particularly if the joint

Figure 2. Microscopic appearances of the femoral head confirming avascular necrosis in association with infection. Section (a) bone with empty osteocyte lacunae and necrotic rnarrow with foci of dystrophiccalcification, ie, avascular necrosis, and section (b) showing chronic pyogenic inflammatory infltrate and granulation tissue formation, the katter related to bone trabeculae undergoing osteoclastic resorption

fluid is foul-smelling or contains gas. Adequate specimens for gram staining and culture of both joint fluid and blood should be obtained under anaerobic conditions in a suitable medium. The cultures should be kept for up to 3 weeks to allow the growth of slow-growing anaerobes. Special culture media may be required and this should be discussed with the bacteriology department prior to obtaining the specimen. Why the patient reviewed here should have developed such an infection is not clear. It would appear that our patient developed an effusion in the arthritic hip due to avascular necrosis and this provided a suitable medium for the organism to settle and grow from haematological spread from unknown primary focus. The principles of treatment of anaerobic septic arthritis are similar to that of other types of septic arthritis. This includes management of underlying disease, appropriate drainage, temporary immobilization ofthe joint and suitable antimicrobial therapy. Metronidazole is the drug ofchoice for most anaerobes but it is advisable to await the culture and sensitivity report prior to antibiotic institution if the clinical conditions will allow this. An early aspiration of the involved joint is advisable in cases of avascular necrosis with or without osteoarthritis if there is the slightest doubt of sepsis; sudden worsening of symptoms from an arthritic hip may not always be due to avascular necrosis. References 1 Heberman ET, Friedenthal RB. Septic arthritis associated with avascular necrosis of the femoral head. Clin Orthop 1978;

134:325-31 2 Martin CM, Merrill RH, Barrett 0. Arthritis due to serratia. J Bone Joint Surg 1970;52A:1450 3 Goldenberg DL, Brandt KD, Cohen AS, Cathart ES. Treatment of septic arthritis. Comparison of needle aspiration and surgery as initial modes of joint drainage. Arthritis Rheum 1975;18:83 4 Ziment I, David A, Finegold SM. Joint infection by anaerobic bacteria: a case report and review of the literature. Arthritis

Rheum 1969;12:627-35

(Accepted 20 December 1988)

Septic arthritis of the hip due to bacteroides-melanogenicus.

Journal of the Royal Society of Medicine Volume 83 February 1990 True spontaneous rupture of the common iliac vein Susan Hill MBBS P J Billings MS F...
832KB Sizes 0 Downloads 0 Views