Introduction

  • Description: Thrombophlebitis is an inflammatory condition of the veins with secondary thrombosis. This may occur in two forms: aseptic or suppurative (septic). The vessels may be either superficial or deep. Risk factors may be present, or the onset may be idiopathic. Risk varies with the location and cause.

  • Prevalence: Two million cases per year in the United States; 10% of nosocomial infections, intravascular (venous or arterial) catheter-related—88/100,000, 1/1600 during pregnancy. Pulmonary embolism is the seventh leading cause of maternal mortality, accounting for 9% of maternal deaths.

  • Predominant Age: Septic—childhood; aseptic—ages 20–30 years; superficial—older than 40 years. Average age for women: 58 years.

  • Genetics: Uncommon—antithrombin III, proteins C and S, and factor XII deficiencies (autosomal dominant with variable penetrance), factor V Leiden or prothrombin C-20210-a genes.

Etiology and Pathogenesis

  • Causes: Sepsis ( Staphylococcus aureus [65%–75%], multiple organisms [14%]), hypercoagulable states (congenital deficiencies, malignancy, pregnancy, high-dose oral contraceptives, Behçet syndrome, Buerger disease, factor V Leiden deficiency), venous stasis (varicose veins), injury to vessel wall. Septic thrombophlebitis may be caused by Candida albicans in unusual cases. (Virchow triad: intimal damage [trauma, infection, or inflammation], stasis, or changes in the blood constituents [changes in coagulability].)

  • Risk Factors: Trauma (general or vascular), prolonged immobility (hospitalization, prolonged air travel), advanced age, obesity, pregnancy or puerperium (higher in multiple gestations), recent surgery, intravascular catheters or drug abuse, steroid or high-dose estrogen therapy (high-dose oral contraceptives), body mass index (BMI) ≥30 kg/m 2 , inflammatory bowel disease, high altitude, hemoglobinopathies, malignancy, nephrotic syndrome, urinary tract infection, homocystinuria, congenital abnormality or heritable thrombophilia.

Figure 79.1, Clinical manifestations of leg vein thrombophlebitis

Signs and Symptoms

  • Asymptomatic

  • Generalized limb pain or swelling

  • Swelling, tenderness, redness along the course of the vein

  • Fever (70% of patients with septic thrombophlebitis)

  • Warmth, erythema, tenderness, or lymphangitis (32%)

  • Systemic sepsis (84% in suppurative cases)

  • Red, tender cord

  • Swelling of collateral veins

Diagnostic Approach

Differential Diagnosis

  • Cellulitis

  • Erythema nodosa

  • Cutaneous polyarteritis nodosa

  • Sarcoid

  • Kaposi sarcoma

  • Ruptured synovial cyst (Baker cyst)

  • Lymphedema

  • Muscle tear, sprain, strain

  • Venous obstruction (secondary to tumor, lymph node enlargement)

  • Associated Conditions: Pulmonary embolism, Budd-Chiari syndrome (hepatic vein thrombosis), renal vein thrombosis, homocystinuria, hypercoagulability states (antiphospholipid antibody syndrome), Behçet syndrome, and varicose veins.

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