Creamish yellow thrombus suggesstive of staph.aureus infection visible protruding out of the right internal jugular vein(pic.1&2).
Septic thrombophlebitis is a condition characterized by venous thrombosis, inflammation, and generalized bacterimia.It generally goes undiagnosed and under reported.Though a rare disease,it has high mortality rates even in the best of hands(upto 50%).
Suppurative thrombophlebitis of the IJV/SVS almost always happen due to central venous lines.Most of these cases are treated conservatively but certain cases demand surgical intervention esp.those who fail to respond to medical management.Occasional surgical approach consists of resection/ligation or thrombectomy of the concerned veins.
We present to you a similar case of septic thrombophlebitis in a burns patient who had severe MRSA infection refractory to all possible antibiotics.Needless to say this patient had central venous lines inserted from both the jugular veins one after the other to maintain parentral nutrition and drug intake.The left jugular puncture site healed to an extent but the right jugular puncture site showed signs of inflammation.Duplex venous scan was suggestive of right IJV thrombosis.X-ray chest showed multiple bilateral rounded non cavitating lesions suggestive of multiple pulmonary abcesses.Patient was in septic shock with grossly deranged heamatological parameters and was on ianotropic support.She was in delirium and all possible efforts by our intensivists to save her in the ICU did not seem to help her out.It is then that the concerned consultant(Plastic surgeon) did talk to me out of sheer frustration of losing her. I had read about this entity before but had never come across a case like this.Only few articles and case reports are available on the internet for reference.
We had limited options in this case and took the patient up for surgery.We excised the right internal jugular vein and found a creamish yellow clot(something unique for me atleast) at it junction with the subclavian vein.It was realized on the operation table that the suppuration was extending into the SVC and that something more has to be done.Postoperatively we gave her thrombolysis along with heparin infusion.The goal of fibrinolytic therapy is to dissolve the fibrin sheath over the thrombus for the drug to act.Otherwise this thrombus can act as a nidus for resistant infection and a source of septic emboli as was in our case.Much to our surprise a seemingly hopeless case where we almost gave up ,we were able to save the patient.
At the time of writing this article the patient is out of the ICU and recovering in the hospital.She is to undergo skin grafting by our cosmetic surgeon.
The idea of writing this article is to keep our minds and eyes open and to think a step further to be ahead of others.
