Scandinavian Journal of Infectious Diseases
ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Septic internal jugular vein thrombosis caused by Fusobacterium necrophorum and mediated by a broken needle George Galyfos, Konstantinos Palogos & Nikolaos Kavouras To cite this article: George Galyfos, Konstantinos Palogos & Nikolaos Kavouras (2014) Septic internal jugular vein thrombosis caused by Fusobacterium necrophorum and mediated by a broken needle, Scandinavian Journal of Infectious Diseases, 46:12, 911-915 To link to this article: http://dx.doi.org/10.3109/00365548.2014.952247
Published online: 07 Oct 2014.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=infd19 Download by: [Australian National University]
Date: 05 November 2015, At: 16:18
Scandinavian Journal of Infectious Diseases, 2014; 46: 911–915
CASE REPORT
Septic internal jugular vein thrombosis caused by Fusobacterium necrophorum and mediated by a broken needle
GEORGE GALYFOS, KONSTANTINOS PALOGOS & NIKOLAOS KAVOURAS Downloaded by [Australian National University] at 16:18 05 November 2015
From the Department of Surgery, General Hospital of Chalkis, Chalkis, Greece
Abstract The injection of drugs into the neck is unusual and thrombosis of the internal jugular vein can be a rare clinical presentation with a high risk for severe complications. We report a case of a 31-year-old male intravenous drug user presenting with fever, shortness of breath and right neck oedema. Laboratory studies revealed elevated inflammation parameters. X-ray imaging revealed a broken syringe needle inside the soft tissues of the neck. Computed tomography (CT) scans of the thorax and brain were unremarkable, while cervical CT showed a fully thrombosed, right internal jugular vein. Intravenous antibiotics were initiated, and modified after identification of an anaerobic Gram-negative oropharynx-derived pathogen (Fusobacterium necrophorum). The patient was discharged after resolution of symptoms under treatment. Septic internal jugular vein thrombosis should always be included in the differential diagnosis of local neck inflammation and systemic sepsis in intravenous drug users. Prompt and aggressive antibiotic treatment is vital, whereas the role of anticoagulation therapy is not definitely known.
Keywords: Intravenous drug use, Fusobacterium necrophorum, Lemierre syndrome, septic thrombophlebitis, anticoagulation
Introduction Injecting drug use may be one of the most common risk factors for deep vein thrombosis [1]. Intravenous crack cocaine and heroin use are known to be particularly damaging to veins, possibly exacerbated by the citric acid used to dissolve the drugs and the local anaesthetic property of the cocaine [2]. However, the injection of drugs into the neck resulting in thrombosis of the internal jugular vein seems to be unusual and there are not many reports in literature, making the differential diagnosis quite challenging. We present a rare case of an intravenous drug user (IVDU) with septic thrombophlebitis of the internal jugular vein.
Case report A 31-year-old Caucasian male presented to our emergency department, complaining of high-grade
fever for 2 days accompanied by chills and shortness of breath. He reported intravenous heroin use for more than 15 years. The rest of his medical history was unremarkable. The temperature was 39°C, the pulse rate was 95/min and the respiratory rate was 25/min. His physical examination revealed tenderness at the right side of the neck, redness and oedema with mild regional lymphadenopathy. Examination of the oropharyngeal cavity, tonsils and lungs was unremarkable. Nuchal rigidity was not noticed. Furthermore, the patient mentioned that during the last 10 months when trying to gain a venous access, he frequently used the jugular veins. He denied any needle sharing or use of contaminated syringes. His usual practice was to lubricate the needle with his saliva and inject without cleaning the skin. On routine laboratory testing, the haemoglobulin was 10 g/dl, the white cell count was 16 200/mm3 with 85% neutrophilia and C-reactive protein (CRP) was elevated (13 mg/dl, normal limits ⬍ 0.5 mg/dl). The rest of the
Correspondence: George Galyfos MD PhD, Department of General Surgery, General Hospital of Chalkis, 48 Gazepi Street, Chalkis, 34100, Evia, Greece. Tel: ⫹ 30 6938764167. Fax: ⫹ 30 22210 84446. E-mail: [email protected] (Received 8 July 2014 ; accepted 29 July 2014 ) ISSN 0036-5548 print/ISSN 1651-1980 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2014.952247
Downloaded by [Australian National University] at 16:18 05 November 2015
912
G. Galyfos et al.
laboratory studies were normal. Serological tests were positive for hepatitis C infection. X-ray study of the neck revealed an almost 2 cm long, metallic object inside the neck at the same height as the fifth cervical vertebra; possibly a broken syringe needle (Figure 1). Additionally, contrastenhanced CT of the neck was ordered, which showed that the right internal jugular vein was fully thrombosed and there was enlargement of the regional lymph nodules (Figure 2). According to CT, the needle was broken inside the surrounding soft tissues and not inside the vein itself. CT scans of the thorax and brain were negative as well. A cardiac ultrasonographic examination was also negative for thrombi or emboli. Empirical antibiotic treatment with intravenous amoxicillin/clavulanate and clindamycin was initiated, although clindamycin was discontinued 3 days later due to gastrointestinal symptoms. The patient became afebrile with clinical improvement. Blood cultures 5 days after admission grew Fusobacterium necrophorum, and the antibiotic regimen was changed to ampicillin-sulbactam plus metronidazole for 14 days intravenously. At the time of discharge, the patient was in good health and he continued treatment per os for 6 more weeks
Figure 1. X-ray of the neck showing the broken needle at the height of the fifth cervical vertebra (arrow).
(amoxicillin/clavulanate and metronidazole). Anticoagulation therapy with low molecular weight heparin (LMWH) was initiated with the diagnosis and continued after discharge as well. The patient was referred to a vascular surgeon after discharge, and the needle was removed after resolution of inflammation and symptoms. To date, the patient is asymptomatic.
Discussion In this report we present an unusual case of an IVDU with septic thrombophlebitis of the neck that resulted from a broken infected needle. Septic internal jugular vein thrombosis (SIJVT) is a rare but potentially life-threatening condition that necessitates early clinical recognition and rapid administration of appropriate therapy [3]. Although termed by some authors a ‘forgotten disease’ in the antibiotic era, this entity is still present but frequently overlooked [3]. Nonspontaneous internal jugular vein thrombosis (IJVT) was an uncommon condition historically associated with deep neck infections during the pre-antibiotic era [4]. However, trauma to the internal jugular vein from catheterization and repeated intravenous injections by drug users are the leading causes of thrombosis today [4]. SIJVT is characterized by venous thrombosis, inflammation and bacteraemia that can lead to fatal complications such as sepsis, pulmonary emboli, and even death [5–7]. The femoral vein remains the most common site of intravenous drug injection [6], although our patient presented with thrombosis of the internal jugular vein. As described by McColl et al., 21.4% of 322 women aged 16–70 years who were drug addicts, and 52.4% of women in this series aged under 40 years showed femoral vein puncture [8]. However, other locations are sought by the drug addicts when the femoral or upper extremity veins cannot be used further. The neck always remains another option, with easy to access visible veins and, as a result, the complication of SIJVT has been reported in such patients lately [5]. The most frequent predominant pathogens of septic thrombophlebitis in IVDUs are Staphylococcus aureus (methicillin-sensitive, MSSA or methicillin-resistant, MRSA), followed by streptococcal species [9]. However, in our patient there was a less common pathogen discovered that is usually associated with Lemierre’s syndrome [10]. Fusobacterium necrophorum is an anaerobic non-mobile filamentous non-spore-forming Gram-negative bacillus, which is part of normal oral flora, and it is the most common anaerobe in sepsis originating from the oropharynx [5]. Penetration of neck veins that are
Downloaded by [Australian National University] at 16:18 05 November 2015
Septic internal jugular vein thrombosis
913
Figure 2. Computed tomography of the neck showing a fully occluded, right internal jugular vein (arrow).
close to the mouth increases the risk of infection by such pathogens. Moreover, contaminating the needle by licking it is always possible in these patients, and has been reported before as well [5]. However, this is the first report of a broken needle inside the internal jugular vein as the major cause. Skin and soft tissue infections (abscesses, cellulitides, infected ulcers) are the most common cause of hospital admission of IVDUs (estimated incidence 21–32%) [11]. Cutaneous and subcutaneous abscesses are the most frequent type of soft tissue infections and occur most commonly when drug users are no longer able to inject intravenously and resort to injection directly into skin or muscle [12]. Finally, malnutrition, immunodeficiency, homeless-
ness and needle-sharing contribute to a high infection rate in these patients [12]. In our case, diagnosis of septic thrombophlebitis was suspected because of the history of IV drug use, local signs of thrombosis and inflammation and positive blood cultures, together with radiological findings consistent with venous obstruction. Usually, the CT findings consist of enlargement of the thrombosed vein, a non-enhancing filling defect in the lumen of the affected vessel, an enhancing vessel wall and opacification of collateral venous channels [13]. In contrast to ultrasound, CT can more readily visualize anatomical structures located in the pelvis, the dorsal cervical region, the base of the skull or the chest cavity [14]. CT may therefore be more useful
Downloaded by [Australian National University] at 16:18 05 November 2015
914
G. Galyfos et al.
in demonstrating the full extent of thrombotic occlusion of proximal veins. Furthermore, CT may delineate pathologies of the structures adjacent to the vein, such as perivenous fluid, soft tissue abscesses or the extent of a concomitant haematoma [14]. Therefore, we selected CT as the first choice in our patient. However, ultrasound techniques are inexpensive, non-invasive and non-ionizing, and have been shown to be accurate in the diagnosis of septic deep venous thrombosis as well, especially in patients with renal failure or contrast medium-associated allergic reactions [13]. Regarding treatment, aggressive antibiotic therapy and surgical intervention for the deep neck infection are recommended [15,16]. The present data suggest that a 2–3 week course of intravenous therapy followed by therapy with oral antibiotics is safe for suppurative thrombophlebitis [17]. However, the indications for anticoagulation remain variable. Although anticoagulation is often recommended in the presence of thrombus progression or septic emboli, the very presence of IJVT does not mandate the need for anticoagulation [3]. Ligation or resection of the thrombosed vein may be reserved for selected cases [1,3]. However, our case did not require any immediate surgical or interventional management. The use of heparin in combination with antibiotics is associated with low mortality in patients with this serious type of infection. Although data from comparative trials are required to draw definitive conclusions, the available evidence suggests that the administration of heparin should be considered early in the management of patients with septic thrombophlebitis [18]. LMWHs have largely replaced intravenous unfractionated heparin in the treatment of peripheral deep vein thrombosis. LMWHs have been shown to be as effective as conventional unfractionated heparin, have no general requirement for therapeutic monitoring, and have a convenient once or twice daily subcutaneous dosage regimen which the patient may self-administer, making it convenient for longterm outpatient usage [19,20]. However, treatment with warfarin after initial anticoagulation with LMWHs is inappropriate for injecting drug users due to their chaotic lifestyle, problems in controlling and monitoring the international normalized ratio (INR), non-compliance with prescribed treatment and poor venous access [18]. Patients should be encouraged to continue treatment for at least 6 weeks and possibly up to 12 weeks in severe cases, although this may not be achieved. It is unlikely that a controlled clinical trial could be accomplished in this patient cohort [20]. Deviation from recommended protocols is associated with a higher rate of treatment failure
and relapse. Making compromises in treatment strategies cannot be justified on the basis of a belief that a patient may not adhere to the prescribed programme. In conclusion, SIJVT is a rare entity that should be included in the differential diagnosis of febrile neck inflammations in IVDUs. CT of the neck, thorax and brain should be included in the investigation to exclude thrombosis and septic emboli. Prompt and aggressive antibiotic treatment should be initiated, whereas the role of anticoagulation therapy is not definitely known. Surgical intervention should be applied only in selected cases. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References [1] Cooke VA, Fletcher AK. Deep vein thrombosis among injecting drug users in Sheffield. Emerg Med J 2006;23:777–9. [2] Cornford CS, Mason JM, Inns F. Deep vein thromboses in users of opioid drugs: incidence, prevalence, and risk factors. Br J Gen Pract 2011;61:e781–6. [3] Tovi F, Fliss DM, Noyek AM. Septic internal jugular vein thrombosis. J Otolaryngol 1993;22:415–20. [4] Chowdhury K, Bloom J, Black MJ, Al-Noury K. Spontaneous and nonspontaneous internal jugular vein thrombosis. Head Neck 1990;12:168–173. [5] Dimitropoulou D, Lagadinou M, Papayiannis T, Siabi V, Gogos CA, Marangos M. Septic thrombophlebitis caused by Fusobacterium necrophorum in an intravenous drug user. Case Rep Infect Dis 2013;2013:870846. [6] Ascher E, Salles-Cunha S, Hingorani A. Morbidity and mortality associated with internal jugular vein thromboses. Vasc Endovascular Surg 2005;39:335–9. [7] Major KM, Bulic S, Rowe VL, Patel K, Weaver FA. Internal jugular, subclavian, and axillary deep venous thrombosis and the risk of pulmonary embolism. Vascular 2008;16:73–9. [8] McColl MD, Tait RC, Greer IA, Walker ID. Injecting drug use is a risk factor for deep vein thrombosis in women in Glasgow. Br J Haematol 2001;112:641–3. [9] Fäh F, Zimmerli W, Jordi M, Schoenenberger RA. Septic deep venous thrombosis in intravenous drug users. Swiss Med Wkly 2002;132:386–92. [10] Karkos PD, Asrani S, Karkos CD, Leong SC, Theochari EG, Alexopoulou TD, et al. Lemierre’s syndrome: a systematic review. Laryngoscope 2009;119:1552–9. [11] Takahashi TA, Merrill JO, Boyko EJ, Bradley KA. Type and location of injection drug use-related soft tissue infections predict hospitalization. J Urban Health 2003;80:127–36. [12] Ebright JR, Pieper B. Skin and soft tissue infections in injection drug users. Infect Dis Clin North Am 2002;16:697– 712. [13] Giyanani VL, Mirfakhraee M, Gerlock AJ Jr, Meyers PC. Computed tomography of internal jugular vein thrombosis. J Comput Tomogr 1985;9:33–7. [14] Kim BY, Yoon DY, Kim HC, Kim ES, Baek S, Lim KJ, et al. Thrombophlebitis of the internal jugular vein (Lemierre syndrome): clinical and CT findings. Acta Radiol 2013; 54:622–7.
Septic internal jugular vein thrombosis
Downloaded by [Australian National University] at 16:18 05 November 2015
[15] Lin D, Reeck JB, Murr AH. Internal jugular vein thrombosis and deep neck infection from intravenous drug use: management strategy. Laryngoscope 2004;114: 56–60. [16] Mertz D, Viktorin N, Wolbers M, Laifer G, Leimenstoll B, Fluckiger U, et al. Appropriateness of antibiotic treatment in intravenous drug users, a retrospective analysis. BMC Infect Dis 2008;8:42. [17] Mertz D, Khanlari B, Viktorin N, Battegay M, Fluckiger U. Less than 28 days of intravenous antibiotic treatment is sufficient for suppurative thrombophlebitis in injection drug users. Clin Infect Dis 2008;46:741–4.
915
[18] Bick RL. Proficient and cost-effective approaches for the prevention and treatment of venous thrombosis and thromboembolism. Drugs 2000;60:575–95. [19] Mackenzie AR, Laing RB, Douglas JG, Greaves M, Smith CC. High prevalence of iliofemoral venous thrombosis with severe groin infection among injecting drug users in North East Scotland: successful use of low molecular weight heparin with antibiotics. Postgrad Med J 2000;76:561–5. [20] Valiukiene L, Naudzi nas A, Unikauskas A. Treatment and prophylaxis of deep venous thrombosis with low molecular weight heparins (meta-analysis of clinical trials). Medicina (Kaunas) 2003;39:352–8.
ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Septic internal jugular vein thrombosis caused by Fusobacterium necrophorum and mediated by a broken needle George Galyfos, Konstantinos Palogos & Nikolaos Kavouras To cite this article: George Galyfos, Konstantinos Palogos & Nikolaos Kavouras (2014) Septic internal jugular vein thrombosis caused by Fusobacterium necrophorum and mediated by a broken needle, Scandinavian Journal of Infectious Diseases, 46:12, 911-915 To link to this article: http://dx.doi.org/10.3109/00365548.2014.952247
Published online: 07 Oct 2014.
Submit your article to this journal
Article views: 74
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=infd19 Download by: [Australian National University]
Date: 05 November 2015, At: 16:18
Scandinavian Journal of Infectious Diseases, 2014; 46: 911–915
CASE REPORT
Septic internal jugular vein thrombosis caused by Fusobacterium necrophorum and mediated by a broken needle
GEORGE GALYFOS, KONSTANTINOS PALOGOS & NIKOLAOS KAVOURAS Downloaded by [Australian National University] at 16:18 05 November 2015
From the Department of Surgery, General Hospital of Chalkis, Chalkis, Greece
Abstract The injection of drugs into the neck is unusual and thrombosis of the internal jugular vein can be a rare clinical presentation with a high risk for severe complications. We report a case of a 31-year-old male intravenous drug user presenting with fever, shortness of breath and right neck oedema. Laboratory studies revealed elevated inflammation parameters. X-ray imaging revealed a broken syringe needle inside the soft tissues of the neck. Computed tomography (CT) scans of the thorax and brain were unremarkable, while cervical CT showed a fully thrombosed, right internal jugular vein. Intravenous antibiotics were initiated, and modified after identification of an anaerobic Gram-negative oropharynx-derived pathogen (Fusobacterium necrophorum). The patient was discharged after resolution of symptoms under treatment. Septic internal jugular vein thrombosis should always be included in the differential diagnosis of local neck inflammation and systemic sepsis in intravenous drug users. Prompt and aggressive antibiotic treatment is vital, whereas the role of anticoagulation therapy is not definitely known.
Keywords: Intravenous drug use, Fusobacterium necrophorum, Lemierre syndrome, septic thrombophlebitis, anticoagulation
Introduction Injecting drug use may be one of the most common risk factors for deep vein thrombosis [1]. Intravenous crack cocaine and heroin use are known to be particularly damaging to veins, possibly exacerbated by the citric acid used to dissolve the drugs and the local anaesthetic property of the cocaine [2]. However, the injection of drugs into the neck resulting in thrombosis of the internal jugular vein seems to be unusual and there are not many reports in literature, making the differential diagnosis quite challenging. We present a rare case of an intravenous drug user (IVDU) with septic thrombophlebitis of the internal jugular vein.
Case report A 31-year-old Caucasian male presented to our emergency department, complaining of high-grade
fever for 2 days accompanied by chills and shortness of breath. He reported intravenous heroin use for more than 15 years. The rest of his medical history was unremarkable. The temperature was 39°C, the pulse rate was 95/min and the respiratory rate was 25/min. His physical examination revealed tenderness at the right side of the neck, redness and oedema with mild regional lymphadenopathy. Examination of the oropharyngeal cavity, tonsils and lungs was unremarkable. Nuchal rigidity was not noticed. Furthermore, the patient mentioned that during the last 10 months when trying to gain a venous access, he frequently used the jugular veins. He denied any needle sharing or use of contaminated syringes. His usual practice was to lubricate the needle with his saliva and inject without cleaning the skin. On routine laboratory testing, the haemoglobulin was 10 g/dl, the white cell count was 16 200/mm3 with 85% neutrophilia and C-reactive protein (CRP) was elevated (13 mg/dl, normal limits ⬍ 0.5 mg/dl). The rest of the
Correspondence: George Galyfos MD PhD, Department of General Surgery, General Hospital of Chalkis, 48 Gazepi Street, Chalkis, 34100, Evia, Greece. Tel: ⫹ 30 6938764167. Fax: ⫹ 30 22210 84446. E-mail: [email protected] (Received 8 July 2014 ; accepted 29 July 2014 ) ISSN 0036-5548 print/ISSN 1651-1980 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2014.952247
Downloaded by [Australian National University] at 16:18 05 November 2015
912
G. Galyfos et al.
laboratory studies were normal. Serological tests were positive for hepatitis C infection. X-ray study of the neck revealed an almost 2 cm long, metallic object inside the neck at the same height as the fifth cervical vertebra; possibly a broken syringe needle (Figure 1). Additionally, contrastenhanced CT of the neck was ordered, which showed that the right internal jugular vein was fully thrombosed and there was enlargement of the regional lymph nodules (Figure 2). According to CT, the needle was broken inside the surrounding soft tissues and not inside the vein itself. CT scans of the thorax and brain were negative as well. A cardiac ultrasonographic examination was also negative for thrombi or emboli. Empirical antibiotic treatment with intravenous amoxicillin/clavulanate and clindamycin was initiated, although clindamycin was discontinued 3 days later due to gastrointestinal symptoms. The patient became afebrile with clinical improvement. Blood cultures 5 days after admission grew Fusobacterium necrophorum, and the antibiotic regimen was changed to ampicillin-sulbactam plus metronidazole for 14 days intravenously. At the time of discharge, the patient was in good health and he continued treatment per os for 6 more weeks
Figure 1. X-ray of the neck showing the broken needle at the height of the fifth cervical vertebra (arrow).
(amoxicillin/clavulanate and metronidazole). Anticoagulation therapy with low molecular weight heparin (LMWH) was initiated with the diagnosis and continued after discharge as well. The patient was referred to a vascular surgeon after discharge, and the needle was removed after resolution of inflammation and symptoms. To date, the patient is asymptomatic.
Discussion In this report we present an unusual case of an IVDU with septic thrombophlebitis of the neck that resulted from a broken infected needle. Septic internal jugular vein thrombosis (SIJVT) is a rare but potentially life-threatening condition that necessitates early clinical recognition and rapid administration of appropriate therapy [3]. Although termed by some authors a ‘forgotten disease’ in the antibiotic era, this entity is still present but frequently overlooked [3]. Nonspontaneous internal jugular vein thrombosis (IJVT) was an uncommon condition historically associated with deep neck infections during the pre-antibiotic era [4]. However, trauma to the internal jugular vein from catheterization and repeated intravenous injections by drug users are the leading causes of thrombosis today [4]. SIJVT is characterized by venous thrombosis, inflammation and bacteraemia that can lead to fatal complications such as sepsis, pulmonary emboli, and even death [5–7]. The femoral vein remains the most common site of intravenous drug injection [6], although our patient presented with thrombosis of the internal jugular vein. As described by McColl et al., 21.4% of 322 women aged 16–70 years who were drug addicts, and 52.4% of women in this series aged under 40 years showed femoral vein puncture [8]. However, other locations are sought by the drug addicts when the femoral or upper extremity veins cannot be used further. The neck always remains another option, with easy to access visible veins and, as a result, the complication of SIJVT has been reported in such patients lately [5]. The most frequent predominant pathogens of septic thrombophlebitis in IVDUs are Staphylococcus aureus (methicillin-sensitive, MSSA or methicillin-resistant, MRSA), followed by streptococcal species [9]. However, in our patient there was a less common pathogen discovered that is usually associated with Lemierre’s syndrome [10]. Fusobacterium necrophorum is an anaerobic non-mobile filamentous non-spore-forming Gram-negative bacillus, which is part of normal oral flora, and it is the most common anaerobe in sepsis originating from the oropharynx [5]. Penetration of neck veins that are
Downloaded by [Australian National University] at 16:18 05 November 2015
Septic internal jugular vein thrombosis
913
Figure 2. Computed tomography of the neck showing a fully occluded, right internal jugular vein (arrow).
close to the mouth increases the risk of infection by such pathogens. Moreover, contaminating the needle by licking it is always possible in these patients, and has been reported before as well [5]. However, this is the first report of a broken needle inside the internal jugular vein as the major cause. Skin and soft tissue infections (abscesses, cellulitides, infected ulcers) are the most common cause of hospital admission of IVDUs (estimated incidence 21–32%) [11]. Cutaneous and subcutaneous abscesses are the most frequent type of soft tissue infections and occur most commonly when drug users are no longer able to inject intravenously and resort to injection directly into skin or muscle [12]. Finally, malnutrition, immunodeficiency, homeless-
ness and needle-sharing contribute to a high infection rate in these patients [12]. In our case, diagnosis of septic thrombophlebitis was suspected because of the history of IV drug use, local signs of thrombosis and inflammation and positive blood cultures, together with radiological findings consistent with venous obstruction. Usually, the CT findings consist of enlargement of the thrombosed vein, a non-enhancing filling defect in the lumen of the affected vessel, an enhancing vessel wall and opacification of collateral venous channels [13]. In contrast to ultrasound, CT can more readily visualize anatomical structures located in the pelvis, the dorsal cervical region, the base of the skull or the chest cavity [14]. CT may therefore be more useful
Downloaded by [Australian National University] at 16:18 05 November 2015
914
G. Galyfos et al.
in demonstrating the full extent of thrombotic occlusion of proximal veins. Furthermore, CT may delineate pathologies of the structures adjacent to the vein, such as perivenous fluid, soft tissue abscesses or the extent of a concomitant haematoma [14]. Therefore, we selected CT as the first choice in our patient. However, ultrasound techniques are inexpensive, non-invasive and non-ionizing, and have been shown to be accurate in the diagnosis of septic deep venous thrombosis as well, especially in patients with renal failure or contrast medium-associated allergic reactions [13]. Regarding treatment, aggressive antibiotic therapy and surgical intervention for the deep neck infection are recommended [15,16]. The present data suggest that a 2–3 week course of intravenous therapy followed by therapy with oral antibiotics is safe for suppurative thrombophlebitis [17]. However, the indications for anticoagulation remain variable. Although anticoagulation is often recommended in the presence of thrombus progression or septic emboli, the very presence of IJVT does not mandate the need for anticoagulation [3]. Ligation or resection of the thrombosed vein may be reserved for selected cases [1,3]. However, our case did not require any immediate surgical or interventional management. The use of heparin in combination with antibiotics is associated with low mortality in patients with this serious type of infection. Although data from comparative trials are required to draw definitive conclusions, the available evidence suggests that the administration of heparin should be considered early in the management of patients with septic thrombophlebitis [18]. LMWHs have largely replaced intravenous unfractionated heparin in the treatment of peripheral deep vein thrombosis. LMWHs have been shown to be as effective as conventional unfractionated heparin, have no general requirement for therapeutic monitoring, and have a convenient once or twice daily subcutaneous dosage regimen which the patient may self-administer, making it convenient for longterm outpatient usage [19,20]. However, treatment with warfarin after initial anticoagulation with LMWHs is inappropriate for injecting drug users due to their chaotic lifestyle, problems in controlling and monitoring the international normalized ratio (INR), non-compliance with prescribed treatment and poor venous access [18]. Patients should be encouraged to continue treatment for at least 6 weeks and possibly up to 12 weeks in severe cases, although this may not be achieved. It is unlikely that a controlled clinical trial could be accomplished in this patient cohort [20]. Deviation from recommended protocols is associated with a higher rate of treatment failure
and relapse. Making compromises in treatment strategies cannot be justified on the basis of a belief that a patient may not adhere to the prescribed programme. In conclusion, SIJVT is a rare entity that should be included in the differential diagnosis of febrile neck inflammations in IVDUs. CT of the neck, thorax and brain should be included in the investigation to exclude thrombosis and septic emboli. Prompt and aggressive antibiotic treatment should be initiated, whereas the role of anticoagulation therapy is not definitely known. Surgical intervention should be applied only in selected cases. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References [1] Cooke VA, Fletcher AK. Deep vein thrombosis among injecting drug users in Sheffield. Emerg Med J 2006;23:777–9. [2] Cornford CS, Mason JM, Inns F. Deep vein thromboses in users of opioid drugs: incidence, prevalence, and risk factors. Br J Gen Pract 2011;61:e781–6. [3] Tovi F, Fliss DM, Noyek AM. Septic internal jugular vein thrombosis. J Otolaryngol 1993;22:415–20. [4] Chowdhury K, Bloom J, Black MJ, Al-Noury K. Spontaneous and nonspontaneous internal jugular vein thrombosis. Head Neck 1990;12:168–173. [5] Dimitropoulou D, Lagadinou M, Papayiannis T, Siabi V, Gogos CA, Marangos M. Septic thrombophlebitis caused by Fusobacterium necrophorum in an intravenous drug user. Case Rep Infect Dis 2013;2013:870846. [6] Ascher E, Salles-Cunha S, Hingorani A. Morbidity and mortality associated with internal jugular vein thromboses. Vasc Endovascular Surg 2005;39:335–9. [7] Major KM, Bulic S, Rowe VL, Patel K, Weaver FA. Internal jugular, subclavian, and axillary deep venous thrombosis and the risk of pulmonary embolism. Vascular 2008;16:73–9. [8] McColl MD, Tait RC, Greer IA, Walker ID. Injecting drug use is a risk factor for deep vein thrombosis in women in Glasgow. Br J Haematol 2001;112:641–3. [9] Fäh F, Zimmerli W, Jordi M, Schoenenberger RA. Septic deep venous thrombosis in intravenous drug users. Swiss Med Wkly 2002;132:386–92. [10] Karkos PD, Asrani S, Karkos CD, Leong SC, Theochari EG, Alexopoulou TD, et al. Lemierre’s syndrome: a systematic review. Laryngoscope 2009;119:1552–9. [11] Takahashi TA, Merrill JO, Boyko EJ, Bradley KA. Type and location of injection drug use-related soft tissue infections predict hospitalization. J Urban Health 2003;80:127–36. [12] Ebright JR, Pieper B. Skin and soft tissue infections in injection drug users. Infect Dis Clin North Am 2002;16:697– 712. [13] Giyanani VL, Mirfakhraee M, Gerlock AJ Jr, Meyers PC. Computed tomography of internal jugular vein thrombosis. J Comput Tomogr 1985;9:33–7. [14] Kim BY, Yoon DY, Kim HC, Kim ES, Baek S, Lim KJ, et al. Thrombophlebitis of the internal jugular vein (Lemierre syndrome): clinical and CT findings. Acta Radiol 2013; 54:622–7.
Septic internal jugular vein thrombosis
Downloaded by [Australian National University] at 16:18 05 November 2015
[15] Lin D, Reeck JB, Murr AH. Internal jugular vein thrombosis and deep neck infection from intravenous drug use: management strategy. Laryngoscope 2004;114: 56–60. [16] Mertz D, Viktorin N, Wolbers M, Laifer G, Leimenstoll B, Fluckiger U, et al. Appropriateness of antibiotic treatment in intravenous drug users, a retrospective analysis. BMC Infect Dis 2008;8:42. [17] Mertz D, Khanlari B, Viktorin N, Battegay M, Fluckiger U. Less than 28 days of intravenous antibiotic treatment is sufficient for suppurative thrombophlebitis in injection drug users. Clin Infect Dis 2008;46:741–4.
915
[18] Bick RL. Proficient and cost-effective approaches for the prevention and treatment of venous thrombosis and thromboembolism. Drugs 2000;60:575–95. [19] Mackenzie AR, Laing RB, Douglas JG, Greaves M, Smith CC. High prevalence of iliofemoral venous thrombosis with severe groin infection among injecting drug users in North East Scotland: successful use of low molecular weight heparin with antibiotics. Postgrad Med J 2000;76:561–5. [20] Valiukiene L, Naudzi nas A, Unikauskas A. Treatment and prophylaxis of deep venous thrombosis with low molecular weight heparins (meta-analysis of clinical trials). Medicina (Kaunas) 2003;39:352–8.
