Septic Thrombophlebitis Workup

Author: Nicholas Connors, MD; Chief Editor: Rick Kulkarni, MD more...

Updated: Mar 22, 2012

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Approach Considerations
Imaging Studies
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References

Approach Considerations

General laboratory studies

The following studies can be performed:

Complete blood count (CBC) - Should be sent for evidence of leukocytosis
Chemistries - Should be sent for evidence of acidosis and electrolyte imbalance in severe infection
Hepatologies - Should be sent if pylephlebitis is suspected

Culture

All febrile patients with suspected septic phlebitis should have blood cultures drawn. Specifically, the diagnosis of catheter-associated deep septic phlebitis is usually made by tip culture. However, the catheter should not be withdrawn in the emergency department (ED) when there is suspicion of thrombus attachment. Cultures of blood from peripheral and central sites should be sent for comparison.

Evident purulent material from peripheral soft-tissue sites should be sent for Gram stain and culture, including cervical cultures and pharyngeal cultures when applicable.

Cerebrospinal fluid (CSF) culture should be sent in the context of suspected meningitis and dural vein thrombophlebitis.

Lumbar puncture

Lumbar puncture should be performed in the context of suspected intracranial infections.

CT scanning with contrast

Contrast-enhanced computed tomography (CT) scanning is generally accepted as the test of choice for most septic thrombophlebitides and should, at minimum, demonstrate a filling defect within the involved vessel. In the context of positive blood cultures, this finding clinches the diagnosis.^[29]

CT scanning is particularly useful in the evaluation of portal, pelvic, and internal jugular vein thrombophlebitis,^[30]as it may also demonstrate the inciting inflammatory process.

Thrombi with surrounding inflammatory changes are noted on CT scans in cases of septic thrombophlebitis in the superior and inferior vena cava.^[31]

Data show detection rates comparable to magnetic resonance (MR) venography for multidetector-row CT angiography in the diagnosis of all types of dural sinus thrombosis.^[32]

MRI

Though less data on the efficacy of magnetic resonance imaging (MRI) exist, it is generally accepted as a useful diagnostic modality for most septic thrombophlebitides.

Intra-abdominal thrombophlebitides are well visualized with MRI and show intraluminal thrombus and abnormal thickening and enhancement of the affected vessel's wall.^{[33, 34]}

MR with MR venography is considered the most sensitive noninvasive modality for the imaging of the dural sinuses.^[32]

Ultrasonography

Ultrasonography can show venous thrombus and is suggestive of thrombophlebitis in the setting of positive blood cultures.^[35]

As the internal jugular vein is easily accessible for sonography, this can be helpful in the diagnosis of Lemierre disease.^[8]

Periportal collaterals, aeroportia, and liver abscesses may be identified by ultrasonography in the setting of pyelophlebitis.^[30]

Ultrasonography was found to be inadequate for septic pelvic thrombophlebitis^[33]and is not used for the diagnosis of dural vein thromboses.

Angiography

Angiography can be helpful in the diagnosis of catheter-related thrombophlebitis because it will demonstrate the fibrin sheath adhered to the catheter tip.

Angiography is the traditional criterion standard for evaluation of all dural sinus thrombophlebitides and will outline a narrowing or obstruction of the sinus due to infected thrombus.^[11]

Proceed to Treatment & Management

Contributor Information and Disclosures

Author

Nicholas Connors, MD Resident Physician, Department of Emergency Medicine, New York Presbyterian Hospital, University Hospital of Cornell and Columbia

Disclosure: Nothing to disclose.

Coauthor(s)

Juliet D Caldwell, MD Assistant Professor, Department of Emergency Medicine, Weill Cornell Medical College; Attending Physician, Department of Emergency Medicine, New York Presbyterian Hospital, Weill-Cornell Medical Center; Attending Physician, Department of Emergency Medicine, Long Island College Hospital

Juliet D Caldwell, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

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

Additional Contributors

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 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