eMedicine Specialties > Emergency Medicine > Infectious Diseases

Thrombophlebitis, Septic: Differential Diagnoses & Workup

Author: Christian Theodosis, MD, MPH, Resident Physician, Section of Emergency Medicine, Yale School of Medicine
Coauthor(s): Craig F Feied, MD, FACEP, FAAEM, FACPh, Professor of Emergency Medicine, Georgetown University School of Medicine; General Manager, Microsoft Enterprise Health Solutions Group; Jonathan A Handler, MD, Director of Informatics, Assistant Professor, Department of Emergency Medicine, Northwestern Memorial Hospital
Contributor Information and Disclosures

Updated: Jul 24, 2009

Differential Diagnoses

Abortion, Septic
Necrotizing Fasciitis
Appendicitis, Acute
Otitis Externa
Bites, Animal
Ovarian Torsion
Bites, Human
Pelvic Inflammatory Disease
Bites, Insects
Peritonsillar Abscess
Candidiasis
Pharyngitis
Catscratch Disease
Pregnancy, Postpartum Infections
Cavernous Sinus Thrombosis
Prostatitis
Cellulitis
Shock, Septic
Cholangitis
Sinusitis
Cholecystitis and Biliary Colic
Thrombophlebitis, Septic
Deep Venous Thrombosis and Thrombophlebitis
Thrombophlebitis, Superficial
Endocarditis
Toxic Shock Syndrome
Erysipelas
Urinary Tract Infection, Female
Mastoiditis

Other Problems to Be Considered

Lymphangitis

Workup

Laboratory Studies

  • When catheter-related sepsis is suspected, blood cultures should be drawn through the line.
    • If imaging studies show thrombus or a fibrin sheath attached to the catheter, fibrinolysis should be performed prior to catheter removal in order to avoid embolization of large clumps of infected material. Once the risk of septic embolization is eliminated, the catheter should be removed in a sterile procedure and the tip should be cut off and sent for culture.
    • When suppurative phlebitis is present, the purulent material that is expressed from the vessel should be sent for Gram stain and cultures to identify the causative organism.
  • Fever, signs of sepsis, and persistent candidemia are characteristic of peripheral septic thrombophlebitis caused by Candida species. Candidal thrombophlebitis of the great vessels is uncommon, but it should be suspected when candidemia persists after removal of a central venous catheter and endocarditis is not believed to be present.
  • White blood cell (WBC) counts are of little value in patients with septic phlebitis, because WBC counts often do not reflect the seriousness of disease and because the WBC may be elevated markedly in patients with thrombophlebitis even in the absence of infection.

Imaging Studies

  • Imaging studies are useful to rule out thrombosis of deep system vessels, but they cannot distinguish between septic phlebitis and nonseptic thrombophlebitis.
  • The injection of contrast material into a central catheter often permits visualization of catheter-associated thrombus or of an extensive fibrin sheath that extends, cloudlike, away from the catheter. When present, a fibrin sheath is an ideal medium for infection.
  • Contrast-enhanced CT or magnetic resonance imaging (MRI) is essential when pursuing the possible diagnosis of internal jugular vein thrombophlebitis. Both CT scan and MRI can identify the extent of thrombus, the local anatomy of the affected tissues, and any pockets of purulent material that may require drainage. Other modalities that can help to make the diagnosis of Lemierre syndrome include gallium scanning, retrograde venography, and duplex ultrasonography.

More on Thrombophlebitis, Septic

Overview: Thrombophlebitis, Septic
Differential Diagnoses & Workup: Thrombophlebitis, Septic
Treatment & Medication: Thrombophlebitis, Septic
Follow-up: Thrombophlebitis, Septic
References
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References

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Further Reading

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Keywords

septic phlebitis, septic thrombophlebitis, septic emboli, septic shock, catheter-related septic phlebitis, suppurative superficial thrombophlebitis, septic pelvic thrombophlebitis, septic ovarian vein thrombophlebitis, septic pelvic phlebitis, Lemierre syndrome

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Contributor Information and Disclosures

Author

Christian Theodosis, MD, MPH, Resident Physician, Section of Emergency Medicine, Yale School of Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Craig F Feied, MD, FACEP, FAAEM, FACPh, Professor of Emergency Medicine, Georgetown University School of Medicine; General Manager, Microsoft Enterprise Health Solutions Group
Craig F Feied, MD, FACEP, FAAEM, FACPh is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Phlebology, American College of Physicians, American Medical Association, American Medical Informatics Association, American Venous Forum, Medical Society of the District of Columbia, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Jonathan A Handler, MD, Director of Informatics, Assistant Professor, Department of Emergency Medicine, Northwestern Memorial Hospital
Jonathan A Handler, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Eddy Lang, MDCM, CCFP (EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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