High risk and low prevalence diseases: Cavernous sinus thrombosis.

INTRODUCTION: Cavernous sinus thrombosis (CST) is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of CST, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: CST is a potentially deadly thrombophlebitic disease involving the cavernous sinuses. The most common underlying etiology is sinusitis or other facial infection several days prior to development of CST, though other causes include maxillofacial trauma or surgery, thrombophilia, dehydration, or medications. Staphylococcus aureus, streptococcal species, oral anaerobic species, and gram-negative bacilli are the most frequent bacterial etiologies. The most prevalent presenting signs and symptoms are fever, headache, and ocular manifestations (chemosis, periorbital edema, ptosis, ophthalmoplegia, vision changes). Cranial nerve (CN) VI is the most commonly affected CN, resulting in lateral rectus palsy. Other CNs that may be affected include III, IV, and V. The disease may also affect the pulmonary and central nervous systems. Laboratory testing typically reveals elevated inflammatory markers, and blood cultures are positive in up to 70% of cases. Computed tomography of the head and orbits with intravenous contrast delayed phase imaging is recommended in the ED setting, though magnetic resonance venography demonstrates the highest sensitivity. Management includes resuscitation, antibiotics, and anticoagulation with specialist consultation. CONCLUSION: An understanding of CST can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

[Clinical analysis of cases of otogenic sigmoid sinus thrombosis in children].

Objective:To analyze the clinical characteristics of middle ear mastoiditis combined with sigmoid sinus thrombophlebitis in children. Methods:Author retrospectively analyzed the clinical data of 6 children with middle ear mastoiditis combined with sigmoid sinus thrombophlebitis who were hospitalized in the Department of Infectious Diseases and Department of Neurology with first diagnosis of fever/headache, and subsequently underwent middle ear mastoidectomy in our department. All patients underwent comprehensive otoscopic, audiologic, imaging, and pathogenetic examinations. Clinical manifestations, pathogenetic features, treatment methods and prognosis were summarized, and the follow-up period was 3-6 months. Results:All 6 cases were first diagnosed with intracranial complications such as fever and headache in the internal medicine department. Within one month, all patients developed ear symptoms including pain, discharge, and hearing loss. Audiologic examination revealed conductive hearing loss in five cases and total deafness in one case. MRI, MRV and MRA examinations suggested that there were 6 cases of middle ear infection combined with thrombophlebitis of the ethmoid sinus, of which 3 cases had thrombus in the ethmoid sinus. 6 cases received surgical treatments: 2 cases of radical mastoidectomy+grommet Insertion, and 4 cases of radical mastoidectomy. Pathogenetic examination identified Streptococcus pneumoniae in three cases, Pseudomonas aeruginosa in one case, Enterobacter cloacae complex in one case, and no pathogens were detected in one case. Postoperative pathology was inflammatory granulation in all 6 cases. Follow-up was 3-6 months with no recurrence of intracranial and middle ear lesions on regular review. Conclusion:Children with recurrent fever, headache, and a recent history of acute and chronic otitis media should be evaluated for the possibility of sigmoid sinus thrombophlebitis, and imaging tests should be performed in a timely manner to clarify the diagnosis. Once diagnosed, surgery to remove the lesions around the ethmoid sinus, smooth drainage combined with antibiotic therapy is the most direct and effective treatment, and anticoagulation therapy is given when necessary. Timely diagnosis, multidisciplinary collaboration, and accurate timing of the management of primary foci and comorbidities are crucial to the treatment of the disease.

Penile Mondor's disease after open hernia repair surgery: A case report.

Background: Penile Mondor's disease (PMD) is a rare syndrome characterized by sclerosis after superficial thrombophlebitis of the superficial penile veins. The most usual appearance of PMD is a tender, palpable, painful, and sometimes visible cord on the dorsal surface of the penis. Its pathogenesis is still unclear, and a standardized treatment has not been established. Case report: A 54-year-old male patient presented with a left-sided indirect reducible inguinal hernia. The patient underwent Lichtenstein's procedure for inguinal hernia repair. On the tenth postoperative day, he returned with PMD confirmed by Doppler ultrasonography examination. Treatment with 4000 UI low molecular weight heparin (LMWH) daily for three weeks resolved the symptoms, but mild venous ectasia just to the proximal part of the penis remained. Discussion: The exact cause of PMD is not well understood, but various studies have identified certain factors associated with an increased risk of the condition. Out of various potential factors that could trigger PMD, the repair of an inguinal hernia has been reported only once. Treatment may involve pain management, anti-inflammatory medications, anticoagulants, and, in some cases, surgery. Conclusion: PMD after open hernia repair surgery is a very rare benign condition. Correct diagnosis and prompt treatment allowed symptom resolution. Residual venous ectasia has no clinical significance other than a cosmetic appearance.

A Rare and Dangerous Combination of COVID-19, Lemierre Syndrome, and Carotid Pseudoaneurysm: A Case Report.

Lemierre syndrome is a rare complication of oropharyngeal infection that causes septic thrombophlebitis in the internal jugular vein. Since the onset of the COVID-19 pandemic, this condition has been dangerously overlooked and poses an even greater threat when complicated by vascular pathologies. A case is presented where the patient required emergency endovascular exclusion of a right internal carotid artery pseudoaneurysm due to Lemierre syndrome. The treatment included stent graft placement and drainage of a neck abscess, along with appropriate antibiotic treatment during hospitalization. Recognizing this diagnosis requires a high index of suspicion, particularly during the COVID-19 pandemic. The complexity of the disease necessitates extensive multidisciplinary collaboration for effective treatment.

Magnetic Resonance Imaging Features of Plantar Vein Thrombosis.

Plantar vein thrombosis (PVT) is an underdiagnosed condition affecting the deep plantar veins, with challenging clinical diagnosis, often presenting with non-specific symptoms that mimic other foot pathologies. This study assessed the magnetic resonance imaging (MRI) features of patients diagnosed with PVT to contribute to the understanding of this condition. We performed the comprehensive analysis of a substantial dataset, including 112 patients, with a total of 130 positive MRI scans (86 of the forefoot and 44 of the ankle) presenting with PVT. Upon evaluating all the veins of the feet, we observed a higher frequency of involvement of the lateral plantar veins (53.1%) when compared to the medial veins (3.8%). The most affected vascular segments in the forefeet were the plantar metatarsal veins (45.4%), the plantar venous arch (38.5%), and the plantar communicating veins (25.4%). The characteristic findings on MRI were perivascular edema (100%), muscular edema (86.2%), venous ectasia (100%), perivascular enhancement (100%), and intravenous filling defects (97.7%). Our study provides valuable insights into the imaging evaluation of PVT and shows that MRI is a reliable resource for such diagnosis.

Superficial thrombophlebitis in the forearm leading to entrapment of the radial nerve branch: a first case report and literature review.

This article reports a case of a female patient admitted with swelling and subcutaneous mass in the right forearm, initially suspected to be multiple nerve fibroma. However, through preoperative imaging and surgery, the final diagnosis confirmed superficial thrombophlebitis. This condition resulted in entrapment of the radial nerve branch, leading to noticeable nerve entrapment and radiating pain. The surgery involved the excision of inflammatory tissue and thrombus, ligation of the cephalic vein, and complete release of the radial nerve branch. Postoperative pathology confirmed the presence of Superficial Thrombophlebitis. Through this case, we emphasize the importance of comprehensive utilization of clinical, imaging, and surgical interventions for more accurate diagnosis and treatment. This is the first clinical report of radial nerve branch entrapment due to superficial thrombophlebitis.

Lemierre's syndrome: A rare complication of acute bacterial pharyngitis.

Lemierre's syndrome is a rare clinical syndrome of septic thrombophlebitis following a bacterial oropharyngeal infection. Lemierre's syndrome can be difficult to recognise and has significant morbidity. We report the case of a young man with Lemierre's syndrome caused by Streptococcus pyogenes, who responded well to 2 weeks of beta-lactam therapy. Contributions: This case report summarises the key presenting features of Lemierre's syndrome and provides a brief literature review considering the South African context.

Delayed onset septic pelvic thrombophlebitis treated by tissue-plasminogen activator following initial treatment for massive right ovarian vein thrombosis and methicillin-resistant Staphylococcus aureus bacteremia: A case report.

Septic pelvic thrombophlebitis (SPT) is a rare condition that forms thrombosis in the pelvic veins, typically the ovarian veins, with subsequent infection and inflammation. We present a case of right ovarian vein thrombosis (ROVT), methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, and delayed onset of SPT symptoms, requiring tissue-plasminogen activator. A 40-year-old woman, G3P2, at 38 weeks' gestation, was admitted with a fever of 39°C. She had cervical insufficiency and had been often on bed rest. Blood culture revealed MRSA and computed tomography revealed a large ROVT. She received vancomycin and direct oral anticoagulant, and her fever resolved by day 3. On day 16, fever recurred with severe pain over the ROVT. Second computed tomography showed thickening of venous wall with enhancement around ROVT, consistent with SPT. Since pain and fever gradually exacerbated despite treatment with DOAC and antimicrobials, she was started on heparin and tissue plasminogen activator on days 23 and 25, respectively. Along with recanalization on the thrombosis by day 29, fever and abdominal pain resolved. We experienced a case of delayed onset SPT associated with MRSA bacteremia and a large ROVT. MRSA bacteremia might cause the originally existing ROVT to become an infection source, resulting in SPT with recurrent symptoms and long-term treatment. Early and strict anticoagulation is crucial in cases with a large thrombosis and bacteremia, due to the high risk of progression to SPT. This case highlights the importance of recanalization for the treatment of SPT and usefulness of administration of tissue-plasminogen activator for the massive thrombosis.

Rapidly Progressive Fatal Pneumococcal Meningitis in a Fully Immunized Child With a History of Facial Bone Fractures.

Meningitis is the inflammation of meninges either septic or aseptic depending on the source of infection. Typical signs and symptoms of meningitis in children include fever, headache, neck stiffness, nuchal rigidity represented by positive Kernig and Brudzinski signs, photophobia, nausea, vomiting, confusion, lethargy, and irritability. Bacterial meningitis is commonly caused by Streptococcus pneumoniae in children over the age of three months. Although there has been a decline in infections due to the introduction of the pneumococcal conjugate and pneumococcal polysaccharide vaccines, there are still reported cases of invasive pneumococcal infections mostly with non-vaccine serotypes. We report a fully immunized six-year-old male patient with a presentation of classic meningitis signs and symptoms who developed rapid progression of disease including sudden and dramatic change in physical exam and subsequent respiratory depression within 12 hours of admission. Our patient had a history of extensive traumatic facial bone fractures six months prior. Our case demonstrates a unique presentation of rapidly progressing pneumococcal meningitis due to a suspected complication of septic thrombophlebitis and subsequent brain herniation in a fully immunized patient six months after a severe traumatic facial injury.

Diagnostic and Therapeutic Challenges in Lemierre Syndrome: A Case Report Using Metagenomic Next Generation Sequencing.

Lemierre syndrome (LS) is a rare and life-threatening condition predominantly caused by Fusobacterium necrophorum. Currently, there are no standardized clinical guidelines for LS management. Here, we describe the case of a 40-year-old male with fever, productive cough, and dyspnea but no sore throat. Diagnostic radiological examinations revealed multiple pulmonary cavitary nodules and an internal jugular vein occlusion. Metagenomic Next-Generation Sequencing (mNGS) of the alveolar lavage fluid identified Fusobacterium necrophorum, thereby confirming the diagnosis of LS. Intriguingly, the patient exhibited a delayed clinical response despite receiving the appropriate antibiotic. After integrating tigecycline into the treatment to address potential co-infecting bacteria, we observed a marked improvement in his clinical symptoms. Subsequent follow-up over 12 weeks post-discharge revealed complete alleviation of symptoms, and a chest CT scan showed marked regression of the lung lesions.

A Case of Lemierre-Like Syndrome in a Pediatric Patient.

Lemierre-like syndrome is a rare, systemic sequelae following a persistent oropharyngeal infection, leading to septic thrombophlebitis of the internal jugular vein (IJV). Lemierre syndrome is caused by the obligate anaerobic organism Fusobacterium necrophorum, innate to the oropharyngeal tract. Lemierre-like syndrome is due to infections caused by other organisms, including methicillin-resistant Staphylococcus aureus (MRSA). We are reporting a case of a five-month-old male who presented with one week of fever that was not alleviated by acetaminophen, bilateral otitis media, and left-sided cervical lymphadenopathy not alleviated with medical therapy. The patient's clinical course continued to deteriorate as he developed respiratory distress that progressed to acute respiratory failure requiring mechanical ventilation support. Extensive laboratory investigation ruled out the causes of primary and secondary immunodeficiencies. Blood cultures were positive for MRSA, and he was treated initially with vancomycin, then switched to linezolid per ENT recommendations, and ultimately needed daptomycin and ceftaroline therapy. A computed tomography (CT) scan of the neck and chest showed deep neck space infection, bilateral loculated pleural empyema, and mediastinitis. The patient required a decortication video-assisted thoracoscopic surgery (VATS), multiple drains, and a mediastinal washout to control the MRSA infection. This report emphasizes that the rapid progression and spread of septic thrombus can become detrimental to a patient's recovery and survival; therefore, it should be recognized early and treated promptly.

Breast Pain Differential: Mondor's Disease of the Breast.

Breast pain is a common concern among women in primary care clinics. A rare cause of breast pain is Mondor's disease (MD), which can present as an acute, painful, erythematous, cord-like induration on the breast or anterior chest wall. The disorder is caused by sclerosing superficial thrombophlebitis of the anterolateral thoracoabdominal wall veins. There does not appear to be a racial or ethnic propensity for this condition; however, it is important to understand that it may be more difficult to see in darker skin types (Fitzpatrick skin types IV-VI) and requires close attention on physical exam. The cause of MD is poorly understood but may be related to direct trauma, strenuous exercise, or hormone changes. We review a case of a 54-year-old woman who presented with an anterior chest wall palpable cord, better visualized with adequate lighting and skin traction, ultimately diagnosed as MD based on clinical findings and imaging studies. Mondor's disease often resolves spontaneously with supportive care, as in this patient's case; however, clinicians should be aware of this rare cause of breast pain and its association with hypercoagulable state, vasculitis, and breast cancer.

Thrombocytopenia in Klebsiella pneumoniae liver abscess: a retrospective study on its correlation with disease severity and potential causes.

Objective: Thrombocytopenia is commonly associated with infectious diseases and serves as an indicator of disease severity. However, reports on its manifestation in conjunction with Klebsiella pneumoniae liver abscess (KPLA) are scarce. The present study sought to elucidate the correlation between thrombocytopenia and KPLA severity and delve into the etiological factors contributing to the incidence of thrombocytopenia. Materials and methods: A retrospective analysis of the clinical data from patients with KPLA admitted between June 2012 and June 2023 was performed. Baseline characteristics, biochemical assessments, therapeutic interventions, complications, and clinical outcomes were compared between patients with and without thrombocytopenia. To investigate the potential etiologies underlying thrombocytopenia, the association between platelet count reduction and thrombophlebitis was examined, with a particular focus on platelet consumption. Furthermore, bone marrow aspiration results were evaluated to assess platelet production anomalies. Results: A total of 361 KPLA patients were included in the study, among whom 60 (17%) had concurrent thrombocytopenia. Those in the thrombocytopenia group exhibited significantly higher rates of thrombophlebitis (p = 0.042), extrahepatic metastatic infection (p = 0.01), septic shock (p = 0.024), admissions to the intensive care unit (p = 0.002), and in-hospital mortality (p = 0.045). Multivariate analysis revealed that thrombocytopenia (odds ratio, 2.125; 95% confidence interval, 1.114-4.056; p = 0.022) was independently associated with thrombophlebitis. Among the thrombocytopenic patients, eight underwent bone marrow aspiration, and six (75%) had impaired medullar platelet production. After treatment, 88.6% of thrombocytopenic patients (n = 47) demonstrated recovery in their platelet counts with a median recovery time of five days (interquartile range, 3-6 days). Conclusions: Thrombocytopenia in patients with KPLA is indicative of increased disease severity. The underlying etiologies for thrombocytopenia may include impaired platelet production within the bone marrow and augmented peripheral platelet consumption as evidenced by the presence of thrombophlebitis.

Uncommon Culprit, Familiar Foe: A Case of Septic Thrombophlebitis of the Internal Jugular Vein Triggered by Klebsiella Bacteremia.

Septic thrombophlebitis of the internal jugular vein is characterized as Lemierre syndrome. Patients typically present with sore throat and fever and may present with a tender neck mass due to thrombophlebitis of the internal jugular vein. We present the case of a 57-year-old male with neck pain, fever, chills, and headaches who was diagnosed with internal jugular vein septic thrombophlebitis associated with catheter-related introduction of bacteria.

Involvement of veterinary students in the placement of intravenous catheters in adult horses in a teaching hospital does not significantly increase the rate of catheter complications.

OBJECTIVE: To determine whether student involvement in intravenous catheter (IVC) placement increases the risk for complications and to report the rate and types of complications associated with IVCs in adult horses in a university teaching hospital. ANIMALS: 455 IVCs placed in 394 horses. METHODS: Data relevant to IVC placement and removal were retrieved from an electronic medical record search including records of adult horses from January 1 to December 31, 2022. Data retrieved from records included the role of the individual who prepared the site and placed the IVC, site of IVC placement, and type of IVC. The reason for removal of the IVC and presence or absence of detectable changes within the vein at the time of removal were documented in addition to clinical data, allowing for classification of each case. Data were reviewed retrospectively, and statistical analyses were performed using mixed-effects logistic regression models. Significance was set at P ≤ .05. RESULTS: The overall rate of complications was 15.6%, and the most common type of complication was swelling of the vein. Students were involved in 87 of 455 IVC site preparations and placements, and there were no statistically significant differences in complication rates between IVC sites prepared or placed by veterinary students versus nonstudent personnel. CLINICAL RELEVANCE: Veterinary personnel and clients may be hesitant to allow student involvement in IVC placement in horses, but these data suggest that student involvement does not increase the risk of IVC complications.

A Multicentric, Prospective, Observational, Single-Arm Registry Study to Assess the Clinical Safety and Effectiveness of Thrombophob Ointment (Heparin Sodium + Benzyl Nicotinate) in Indian Patients With Thrombophlebitis.

Purpose Thrombophlebitis is a frequent intravenous (IV) therapy consequence. Topical heparin for seven days is used as a treatment for thrombophlebitis. This study was performed to evaluate the clinical safety and effectiveness of the combination of heparin sodium & benzyl nicotinate (Thrombophob Ointment, manufactured by Zydus Healthcare Ltd., Ahmedabad, India) in thrombophlebitis patients in India. Methods A study carried out by 118 Indian doctors examined 2002 thrombophlebitis patients from 2016-2023, prescribing ointment containing heparin sodium and benzyl nicotinate. Patients were followed up on day three and day seven after starting the treatment, and safety and effectiveness were recorded, including adverse events. Result A total of 2002 patients were included in the study and males were predominant (58.15%). IV fluids (60.58%) were the leading cause of thrombophlebitis. The study found notable improvements in key markers of venous health over time. Compared to baseline, patients experienced significantly reduced severity of phlebitis, shorter venous lesion lengths, and lower pain and tenderness scores by both day 3 and day 7 (p<0.001 for all comparisons). Furthermore, these improvements continued between day 3 and day 7, indicating sustained positive effects (p<0.001 for all comparisons). After the application of the ointment, very few patients experienced adverse effects (0.25% on day three and 0.05% on day seven). Treatment effectiveness was excellent in 72% of patients, and treatment safety was excellent in 93% of patients. Conclusion The ointment containing heparin sodium and benzyl nicotinate was well tolerated and efficacious in the treatment of thrombophlebitis in Indian patients.

Case report of Mondor disease in a 49-year-old Albanian woman.

INTRODUCTION AND IMPORTANCE: Mondor Disease is superficial thrombophlebitis mostly located in the thoracic-abdominal wall, mid-upper arm, and penis. The disease can affect all people over 30 years old regardless of race, ethnicity but affects women more than men. The importance of this study case consists on being the first reported case of Mondor Disease in Albania. CASE PRESENTATION: In this study, a case of superficial thrombophlebitis affecting the thoraco-epigastric veins in the right chest wall is reported. Evidence of a palpable cord in the inferior outer quadrant of the breast was noted. The patient, a 49-year-old female who has been in menopause from March of 2021, presented with chest pain ought to two months of exaggerated physical activity. CLINICAL DISCUSSION: A detailed subjective and objective examination was performed. All laboratory data, including tests for COVID-19, showed normal range value except ESR. For 2 weeks under treatment with Ibuprofen, the chest pain was subsided but the palpable cord in the chest wall was persistent. CONCLUSION: Reviewing the literature and after the Color Doppler examination it has been concluded in this diagnose. It was difficult to determine the diagnosis because of no previous experience with such clinical case.

Pediatric Lemierre's Syndrome: A Comprehensive Literature Review.

BACKGROUND: Lemierre syndrome is a rare, potentially fatal complication of oropharyngeal infections characterized by septic thrombophlebitis of the internal jugular vein. It primarily affects healthy adolescents and young adults. Its incidence declined after the antibiotic era, but it may have resurged in recent decades, likely due to judicious antibiotic use and increasing bacterial resistance. Prompt diagnosis and treatment are imperative to prevent significant morbidity and mortality. METHODS: Lemierre syndrome has been called "the forgotten disease," with a reported incidence of around 3.6 cases per million. The mean age at presentation is around 20 years old, though it can occur at any age. Lemierre Syndrome follows an oropharyngeal infection, most commonly pharyngitis, leading to septic thrombophlebitis of the internal jugular vein. F. necrophorum is the classic pathogen, though other organisms are being increasingly isolated. Metastatic infections, especially pulmonary, are common complications. Contrast-enhanced CT of the neck confirming internal jugular vein thrombosis is the gold standard for diagnosis. Long-course broad-spectrum IV antibiotics covering anaerobes are the mainstays of the disease's treatment. Anticoagulation may also be considered. Mortality rates are high without treatment, but most patients recover fully with appropriate therapy. CONCLUSIONS: Lemierre syndrome should be suspected in patients with prolonged pharyngitis followed by unilateral neck swelling and fevers. Early diagnosis and prompt antibiotic therapy are key, given the potential for disastrous outcomes if untreated. An increased awareness of Lemierre syndrome facilitates its timely management.