Case Presentation

Case Presentation

Case Presentation NOLAN IRISH HPI 66 y/o male presenting initially presenting with 3 day hx of n/v. Recently diagnosed with gastric adenocarcinoma 1 month prior s/p port placement GI was consulted on admission and elected to perform upper GI series which revealed moderate gastric outlet obstruction Patient was to begin neoadjuvant chemo and GI elected not to place a stent due to the possibility of stent migration

HPI continued 2 days after admission the patient developed right neck pain and swelling U/S RUE revealed an occlusive thrombi in the right jugular and subclavian vein Heparin was started 2 days later the patient developed a fever with leukocytosis UA and CXR were negative Blood cultures and urine cultures were drawn Patient was started on vancomycin HPI continued Blood culture gram stain showed (port)

GPC in pairs and chains Culture (aerobic bottle): enterococcus faecalis UC negative ID was consulted History Continued PMH Recently diagnosed gastric adenocarcinoma

OSA Remote hx of tobacco abuse DM HTN HLD History Continued Meds ASA

Docusate Norco Lisinopril/hctz Ranitidine Tramadol Allergies NKDA History Continued Social History Tobacco: 1ppd for 15years, Quit 5 years ago ETOH: None Drugs: None

Currently retired Denies recent travel but admits to taking a cruise to Belize 1 year ago No pet ownership Physical Exam VS BP 126/82 P 83 T99.3 RR18 Sat 98% RA Gen A&OX3 NAD HEENT NC/AT PERRL EOMI No LAD No mucosal lesions CV RRR w/o M R G right chest port w/o erythema, drainage, or TTP Pulm CTAB Abd SNT ND w/+BS Ext no splinter hem or lesions on his hands,

no edema Labs WBC 4.8 RBC 8.8 HCT 27.1 Pl 270 BMP unremarkable Repeat BC following day pending Assessment and Plan Septic Thrombophlebitis Continue anticoagulation Tailor abx to sensitivities when they become available Surgical removal of Port Vascular consult to evaluate for septic

thrombophlebitis and to assess for surgical intervention TTE and if negative TEE CT abd/pelvis Enterococcus faecalis Bacteremia As above Continued BC: enterococcus faecalis Amp S Linezolid S Cipro S Imepenem DS Tetracycline R

Vanc S Repeat BC negative Continued Patient remained afebrile and no leukocytosis on labs Primary team discontinued vanc and started ampicillin TTE negative for vegetation Port was removed(no mention of exudates on op note, tip not cultured), left IJ placed, received neoadjuvant chemo cycle #1 out of 4 (cisplatin/taxoterene) Patient developed tinnitus Vascular evaluated and could not assess for septic thrombophlebitis. No surgical intervention. CT abd/pelvis negative

Official Recs Since septic thrombophlebitis cannot be ruled out ID recommend 6 wks of IV daptomycin 6mg/kg Q24hrs vs 12 wks IV amp and vanc (tinnitus) Patient was d/c to CLC with 6 wks IV dapto with weekly labs including CBC, CMP, ESR, CRP, and CK Septic Thrombophlebitis Definition: Venous thrombosis associated with inflammation in the setting of bacteremia Suspect in a patient with

Persistent bacteremia (after 72 hrs) with appropriate antimicrobial therapy and in a pt with a venous catheter Types Peripheral Jugular Vena cava Portal vein

Pelvic Veins Peripheral ST Incidence is highest in: Burn victims Steroid IV drug users Complications: Septic Emboli Endocarditis Arteritis

Patent foramen ovale Microbiology Staph aureus Strep Gram neg Peripheral ST Diagnosis Culture

BC Culture exudates Venous aspirate culture Vein culture Positive imaging

u/s- can also be helpful to detect underlying abscess High resolution CT- filling defect, thrombus, soft tissue swelling MRI Peripheral ST Treatment Cover staph: vancomycin Cover gram neg: rocephin Tailor abx to sensitivities but remember staph

Jugular vein ST Incidence highest in: Pharyngitis Dental infections Infectious mononucleosis IV catheters Usually caused by migration of bacteria through deep tissues (pharynx to lateral pharyngeal space) Microbiology Oral Flora

Most Common: Fusobacterium Necrophorum Jugular vein ST Diagnosis BC + imaging Antimicrobials B lactamase resistant B lactams

Unasym (amp/sulbactam) Zosyn Carbapenems Vancomycin Pelvic vein Pelvic ST Peripartum (hypercoagulability and venous stasis)and typically occur within 3 wks of delivery Endometritis C section PID Diverticulitis

appendicitis Pathogens Staph Strep Anaerobes Portal vein Intrabdominal infections such as diverticulitis and appendicitis Signs

Hepatomegaly jaundice Pathogens Bacteroides Fragilis E coli Klebsiella Imaging

CT MRI- thickening and enhancement of the vessel wall Caveats Anticoagulation Controversial but recommended if there is evidence of extension of the thrombus Surgery

Generally performed if patient is septic or failure of response to initial therapy I&D and possibly excision of vein Citations Spellman, Denis. "Suppurative (septic) thrombophlebitis." Evidence-Based Clinical Decision Support at the Point of Care | UpToDate. UpTodate, Aug. 2013. Web. 5 Oct. 2014. Spellman, Denis. "Suppurative (septic) thrombophlebitis." Evidence-Based Clinical Decision Support at the Point of Care | UpToDate. UpToDate, Aug. 2013. Web. 6 Oct. 2014. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious

Diseases Society of America. Clin Infect Dis 2009; 49: Andes DR, Urban AW, Acher CW, Maki DG. Septic thrombosis of the basilic, axillary, and subclavian veins caused by a peripherally inserted central venous catheter. Am J Med 1998; 105:446.

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