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Thrombophlebitis, Superficial



Ovid: 5-Minute Sports Medicine Consult, The


Thrombophlebitis, Superficial
Jeffrey M. Mjaanes
Michael Hanna
Basics
Description
  • Superficial thrombophlebitis is an inflammatory condition of the veins with clinical findings of pain, tenderness, induration, and erythema of a superficial vein with secondary thrombosis.
  • Septic (suppurative) thrombophlebitis types:
    • Iatrogenic
    • Infectious: Mainly syphilis and psittacosis
  • Aseptic thrombophlebitis types:
    • Primary hypercoagulable states: Disorders with measurable defects in the proteins of the coagulation and/or fibrinolytic systems
    • Secondary hypercoagulable states: Clinical conditions with a risk of thrombosis
  • System(s) affected: Cardiovascular
  • Synonym(s): Phlebitis; Phlebothrombosis; Superficial venous thrombosis
  • Abbreviations: DVT = deep vein thrombosis; LMWH = low-molecular-weight heparin
Pediatric Considerations
  • Pediatric: Subperiosteal abscesses of adjacent long bone may complicate.
  • Geriatric: Septic thrombophlebitis is more common; prognosis poorer.
  • Others: N/A
Pediatric Considerations
  • Warfarin and NSAIDs are contraindicated.
  • Associated with increased risk of aseptic superficial thrombophlebitis
Alert
Note: Potentially lethal misnomer is use of now abandoned term superficial femoral vein thrombosis, which is actually a DVT and should be treated as such.
Epidemiology
Incidence
  • Septic:
    • Up to 10% of all nosocomial infections
    • Incidence of catheter-related thrombophlebitis is 88/100,000.
    • Develops in 4–8% if cutdown is performed
    • More common in childhood
    • Predominant gender: Male = Female
  • Aseptic primary hypercoagulable state:
    • Antithrombin III and heparin cofactor II deficiency incidence is 50/100,000.
    • Antithrombin III and heparin cofactor II deficiency: Neonatal period, but 1st episode usually at age 20–30 yrs
    • Proteins C and S deficiency: Before age 30
  • Aseptic secondary hypercoagulable state:
    • Trousseau syndrome incidence in malignancy 5–15%
    • Trousseau syndrome incidence in pancreatic carcinoma 50%
    • In pregnancy, 49-fold increased incidence of phlebitis
    • Superficial migratory thrombophlebitis in 27% of patients with thromboangiitis obliterans
    • Mondor disease (superficial phlebitis of the breast): Women ages 21–55 yrs; also can occur in dorsal penile vein in men
    • Thromboangiitis obliterans onset: 20–50 yrs
    • Predominant gender: Mondor: Female > Male (2:1); thromboangiitis obliterans: Female > Male (1–19% of clinical cases)
Risk Factors
  • Nonspecific:
    • Immobilization
    • Obesity
    • Advanced age
    • Postoperative states
  • Septic:
    • IV catheter
    • Duration of IV catheterization (68% of cannulas have been left in place for 2 days)
    • Emergent placement of catheter
    • Cutdowns
    • Cancer, debilitating diseases
    • Steroids
    • Incidence is 40 times higher with plastic cannulas (8%) than with steel or scalp cannulas (0.2%)
    • Thrombosis
    • Dermal infection
    • Burn patients
    • Lower extremities IV catheter
    • IV antibiotics
    • AIDS
    • Varicose veins
  • Antithrombin II and heparin cofactor II deficiency:
    • Pregnancy
    • Oral contraceptives
    • Surgery, trauma, infection
  • In pregnancy;
    • Increased age
    • HTN
    • Eclampsia
    • Increased parity
  • Thromboangiitis obliterans: Persistent smoking
  • Mondor disease:
    • Breast abscess
    • Antecedent breast surgery
    • Breast augmentation
    • Reduction mammoplasty
Genetics
  • Septic: No known genetic pattern
  • Antithrombin III deficiencies: Autosomal dominant
  • Proteins C and S deficiency: Autosomal dominant with variable penetrance
  • Disorders of fibrinolytic system: Congenital defects, inheritance variable
  • Dysfibrinogenemia: Autosomal dominant
  • Factor XII deficiency: Autosomal recessive

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General Prevention
  • Use of scalp vein cannulas
  • Avoidance of lower extremity cannulations
  • Insertion under aseptic conditions
  • Secure anchoring of the cannulas
  • Replacement of cannulas, connecting tubing, and IV fluid every 48–72 hr
  • Neomycin-polymyxin B-bacitracin ointment in cutdown
Etiology
  • Septic:
    • Staphylococcus aureus in 65–78%
    • Enterobacteriaceae, especially Klebsiella
    • Multiple organisms in 14%
    • Anaerobic isolate rare
    • Candida spp.
    • Cytomegalovirus in AIDS patients
  • Aseptic primary hypercoagulable state:
    • Antithrombin III and heparin II deficiency
    • Protein C and protein S deficiency
    • Disorder of tissue plasminogen activator
    • Abnormal plasminogen and coplasminogen
    • Dysfibrinogenemia
    • Factor XII deficiency
    • Lupus anticoagulant and anticardiolipin antibody syndrome
  • Aseptic secondary hypercoagulable states:
    • Malignancy (Trousseau syndrome: Recurrent migratory thrombophlebitis): Seen most commonly in metastatic mucin or adenocarcinomas of the GI tract (pancreas, stomach, colon, and gall bladder), lung, prostate, ovary
    • Pregnancy
    • Oral contraceptives
    • Infusion of prothrombin complex concentrates
    • Behçet disease
    • Buerger disease
    • Mondor disease
Commonly Associated Conditions
  • DVT: Superficial and deep vein thromboses (DVTs) can occur together from direct extension or noncontiguous findings.
    • Incidence: Coexisting conditions 15% of time (1)[C]
    • Both more likely in a hypercoagulable state
    • Lower extremity superficial thrombophlebitis of great saphenous vein thought to be associated with DVTs (especially above knee) (1)[C]
  • Varicose veins
  • Systemic diseases such as pancreatic or other abdominal cancers
  • Hypercoagulable states such as Factor V Leiden, prothrombin gene mutation, antithrombin III (AT-III), protein C and protein S deficiencies
  • Surgery
  • Trauma, burns
  • Obesity, pregnancy
  • Thromboangiitis obliterans
Diagnosis
Pre Hospital
Treat initially with support stockings, elevation, and OTC analgesics, such as acetaminophen, or NSAIDs, such as ibuprofen.
History
  • Swelling over affected vein: May feel firm and “cordlike”
  • Redness and warmth of affected vein and area
  • Pain and tenderness to palpation
Physical Exam
  • Swelling, tenderness, mild erythema along the course of the affected vein(s); palpable “cord”
  • May look like cellulitis or erythema nodosa
  • Fever in 70% of patients
  • Warmth, significant erythema, tenderness, or lymphangiitis in 32%
  • Signs of systemic sepsis in 84% in suppurative thrombophlebitis (hypotension, tachycardia, shallow respirations, altered mental status, multiorgan failure)
Diagnostic Tests & Interpretation
Lab
  • CBC
  • Blood culture
  • Coagulation assay and special tests (eg, Factor V Leiden) may be indicated.
  • Other tests:
    • Doppler or duplex US
    • Venography
    • Septic:
      • Bacteremia in 80–90%
      • Culture of IV fluid bag and tip
      • Leukocytosis
    • Aseptic:
      • Acute-phase reactant
      • Patients with single episode of superficial thrombophlebitis do not require hypercoagulable screening. Screen for recurrent cases without known risk factors (2)[C].
        • Factor levels
        • Protein C and S
        • Thrombin activity
        • Platelet function test
  • Doppler or duplex US
  • Venography
  • Septic:
    • Bacteremia in 80–90%
    • Culture of IV fluid bag and tip
    • Leukocytosis
  • Aseptic:
    • Acute-phase reactant
    • Patients with single episode of superficial thrombophlebitis do not require hypercoagulable screening. Screen for recurrent cases without known risk factors (2)[C].
      • Factor levels
      • Protein C and S
      • Thrombin activity
      • Platelet function test
  • Drugs that may alter lab results: In sepsis, broad-spectrum antibiotics
  • Disorders that may alter lab results: N/A

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Imaging
  • US of veins reveals an increase in the diameter of the lumen (can detect extension of thrombus but less useful in regions deep to the clavicle or mandible).
    • Upper extremity superficial thrombophlebitis and saphenous thrombophlebitis below the knee do not require imaging in absence of risk factors for DVT (2)[C].
    • Saphenous thrombophlebitis above the knee is more likely to progress to DVT and requires diagnostic US and follow-up US in 3–7 days (2)[C].
  • Chest x-ray: Multiple peripheral densities or a pleural effusion consistent with pulmonary embolism, abscess, or empyema
  • Bone and gallium scan: For associated subperiosteal abscess in septic thrombophlebitis
  • High-resolution CT scan with contrast material: Most useful for jugular or vena caval septic thrombophlebitis
  • Venography (more invasive than above)
  • Evaluation of complications (DVT and others)
Diagnostic Procedures/Surgery
  • Leukocyte imaging
  • Skin biopsy helpful in recurrent and migratory types as well as unclear cases
Pathological Findings
  • The affected vein is enlarged, tortuous, and thickened.
  • Associated perivascular suppuration and/or hemorrhage
  • Vein lumen may contain pus and thrombus.
  • Endothelial damage, fibrinoid necrosis, and thickening of the vein wall
Differential Diagnosis
  • Cellulitis
  • Erythema nodosa
  • Cutaneous polyarteritis nodosa
  • Sarcoid granuloma
  • Kaposi sarcoma
  • Hyperalgesic pseudothrombophlebitis
  • Panniculitis
  • Insect bite

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Ongoing Care
Follow-Up Recommendations
Activity
Patient Monitoring
  • Septic:
    • Routine WBC count and differential and culture
    • Repeat culture from the phlebitic vein
  • Aseptic:
    • For above-the-knee clots of the great saphenous vein, monitor with US after 3–7 days to exclude progression (1).
    • Clinical follow-up to rule out secondary complications and improvement
    • Repeat of blood studies for fibrinolytic system, platelets, and factors
Diet
No restrictions
Patient Education
  • Avoid trauma.
  • Be alert to change in skin color.
  • Be alert to tenderness over extremities.
Prognosis
  • Septic: High mortality (50%) if untreated
  • Aseptic:
    • Usually benign course: Recovery in 7–10 days
    • Antithrombin III and heparin cofactor deficiency: Recurrence rate is 60%.
    • Proteins C and S: Recurrence rate is 70%.
    • Prognosis depends on development of DVT and early detection of complications.
    • Aseptic thrombophlebitis can be isolated, recurrent, or migratory.
See Also
  • Thrombosis, deep vein (DVT)
  • Cellulitis
Codes
ICD9
  • 451.0 Phlebitis and thrombophlebitis of superficial vessels of lower extremities
  • 451.11 Phlebitis and thrombophlebitis of femoral vein (deep) (superficial)
  • 451.82 Phlebitis and thrombophlebitis of superficial veins of upper extremities


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