History
Superficial septic phlebitis most often begins with a localized break in the skin, such as placement of an intravenous catheter, a puncture wound, an insect bite, a phlebotomy attempt, or an intravenous injection. Tenderness and erythema are often apparent at the initial site of infection. The original portal of entry may become less obvious over time, as pain, tenderness, swelling, and redness spread along the entire course of the infected vessel.
Baker et al, in a review of 100 patients with peripheral septic phlebitis, reported that 83% of patients note pain as the presenting complaint. Fever occurred in 44%, swelling in 37%, and spontaneous drainage of pus in 9%. [4] Intravenous drug abusers often have localized areas of cellulitis or even frank abscesses at the sites of injection.
Thrombophlebitis in the deep veins is more insidious and typically presents with isolated fever, particularly in patients with catheter-related disease. Usually, there is no pain or swelling at the site of the central venous catheter. Thrombosis of intra-abdominal vessels may also present with abdominal pain and discomfort. [16] Hepatomegaly and jaundice are other symptoms that may also occur in the setting of pyelophlebitis.
Recent childbirth and recent pelvic surgery are important clues in the diagnosis of pelvic thrombophlebitis. Whereas ovarian vein thrombophlebitis is usually diagnosed within 1 week of delivery, septic thrombophlebitis of the ileofemoral vessels typically is seen later. [15] Fever is frequently present, and the patient may also complain of upper thigh or lower abdominal pain, depending on which vessels are involved. [29]
Lemierre syndrome
Sore throat and fever are clues to the diagnosis of Lemierre syndrome, with both symptoms noted in more than 80% of patients. Other symptoms include swollen or tender neck (52%), vague gastrointestinal complaints (50%), and pleuritic chest pain suggesting embolic phenomena to the lungs (31%). [10]
Dural sinus thrombophlebitis
The vast majority of patients with dural venous sinus thrombophlebitis present with severe headache. Clues in the case of cavernous sinus thrombosis include facial or oropharyngeal infection and visual disturbances signifying cranial nerve involvement. The pain of cavernous sinus thrombosis is typically retroorbital in the region of the ophthalmic and maxillary branches of the fifth cranial nerve, and fever; periorbital swelling may also be noted by some patients. [12]
Since lateral sinus thrombosis is generally a complication of middle ear and mastoid infection, most patients present with prolonged earache and fever. Profound headache becomes the predominant symptom once thrombosis ensues. Nausea and vomiting are other nonspecific findings that can help guide the clinician. Vertigo, diplopia, and photophobia are suggestive clues that sometimes occur. Superior sagittal sinus thrombosis presents as profound and worsening headache in the setting of established bacterial meningitis. [12]
Physical Examination
Local signs of phlebitis include the traditional cardinal signs of inflammation: calor, dolor, rubor, and tumor (heat, pain, redness, and swelling). Simple phlebitis may produce a painful cord, blanching erythema, and streaking along the venous channel. Septic thrombophlebitis presents with the same symptoms plus fever. [30]
According to Baker et al, in a review of 100 patients with peripheral septic phlebitis, fever was found in 63% patients, erythema and edema were seen in 62% of patients, abscess in 43%, a palpable cord in 20%, and lymphadenopathy in 13%. [4] Suppurative phlebitis is recognized when any amount of purulent material can be expressed from within or around the lumen of a vessel.
In contrast, central line–associated deep vein phlebitis is often clinically occult, because the infected thrombus is located in the region of the catheter tip. Occasionally, erythema, purulence, or surrounding cellulitis at the insertion site is present and should alert the clinician to the possibility of septic thrombophlebitis in the deep vein. [7] If deep system blood flow is obstructed, extremity pain and edema may develop. Verghese et al reported a small series in which 66% of patients with central venous occlusion had corresponding extremity swelling. [7]
Nonspecific findings in pelvic phlebitis, ovarian phlebitis, and pyelophlebitis include fever, abdominal tenderness, and vomiting. Patients often appear clinically ill, with sepsis sometimes apparent on presentation. Helpful, but less common, findings of pyelophlebitis include hepatomegaly and jaundice, [16] whereas cervical motion tenderness and purulent cervical discharge are often discovered in patients with pelvic and ovarian vein disease.
Lemierre syndrome
Early clinical findings in Lemierre syndrome are indistinguishable from pharyngitis, consisting of fever and oropharyngeal pain. An exudative tonsillitis is common, but not invariably present, with pharyngeal pseudomembranes and ulceration occasionally noted. A high degree of clinical suspicion is required, as some patients present with no pharyngeal findings at all.
Tenderness, swelling, and pain over the angle of the jaw are extremely helpful, but they present in only about 52% of patients. [10]
In fact, many patients may present with clinical signs indicative of metastatic disease, such as septic pulmonary emboli with hypoxemia and hemodynamic instability. Findings of septic arthritis and distant soft-tissue infections are also not uncommon. [8] Late in the disease, symptoms progress to severe prostration with respiratory distress.
Sinus thrombophlebitis
The physical findings of thrombophlebitis of the dural sinuses can be specific to the particular sinus involved. Cavernous sinus pathology results in fever in 94% of patients; the triad of ptosis, proptosis, and chemosis in 95% of patients; extraocular movement palsies in 88% of patients; and abnormal fundi in 65% of patients. Other notable signs are lethargy; abnormal ear, nose, and throat (ENT) examination findings; and nuchal rigidity. [12]
An abnormal ear examination, such as posterior auricular swelling and tenderness, purulence from a ruptured tympanic membrane (TM), or a dull, erythematous TM, was noted in 98% of patients with lateral sinus thrombosis. Sixty-five percent of patients with sagittal sinus septic thrombophlebitis present with altered mental status, while 61% have motor deficits. [12]
