|Year : 2022 | Volume
| Issue : 2 | Page : 152-154
Great saphenous vein suppurative thrombophlebitis due to Fusobacterium necrophorum infection
Department of Surgery, College of Medicine, Jazan University, Jazan, Saudi Arabia
|Date of Submission||03-Jul-2022|
|Date of Decision||29-Jul-2022|
|Date of Acceptance||05-Aug-2022|
|Date of Web Publication||22-Aug-2022|
College of Medicine, Jazan University, Jazan
Source of Support: None, Conflict of Interest: None
Fusobacterium necrophorum (F. necrophorum) is an anaerobic Gram-negative bacterium which does not form spores. F. necrophorum is usually associated with Lemierre's syndrome. The syndrome is characterized by thrombosis of the internal jugular vein with septicemia followed by oropharyngeal infection. In the present case report, a 27-year-old male with a significant medical history of intravenous drug use was presented in the emergency department. The patient presented a 3-day history of left lower extremity pain, redness, and swelling. His serological tests were positive for hepatitis C infection. The Duplex ultrasound (US) of the left lower extremity revealed extensive suppurative thrombophlebitis. The blood culture grew F. necrophorum, thus the patient was treated with IV ampicillin for 2 weeks, followed by additional 2 weeks of oral amoxicillin. At follow-up, 3 weeks later, the patient reported significant improvement in his symptoms. Three months later, lower extremity duplex in the US revealed resolving suppurative thrombophlebitis.
Keywords: Fusobacterium necrophorum, great saphenous veins septic thrombophlebitis
|How to cite this article:|
Mawkili A. Great saphenous vein suppurative thrombophlebitis due to Fusobacterium necrophorum infection. Saudi J Health Sci 2022;11:152-4
| Introduction|| |
Fusobacterium necrophorum (F. necrophorum) is a Gram-negative anaerobic bacterium. F. necrophorum is a nonspore-forming bacillus which constitutes only 1% of bacteremias and very few cases are reported in the literature. F. necrophorum is usually associated with peritonsillar abscesses, tonsillitis, and pharyngitis similar to group A Streptococcus. It is accounted for around 10% of cases of pharyngitis in young adults and adolescents.,
Peripheral vein septic thrombophlebitis is commonly caused by indwelling catheters but has also been reported in intravenous drug users (IVDUs). The most common pathogens for septic thrombophlebitis in such population are Staphylococcus aureus (methicillin-susceptible staph (MSSA) or methicillin-resistant staph (MRSA)) and streptococci species. F. necrophorum has also been reported as a cause of septic thrombophlebitis of the internal jugular vein among IVDUs. However, superficial vein thrombophlebitis caused by Fusobacterium species is unusual. In the present report, a case of great saphenous veins septic thrombophlebitis caused by F. necrophorum is reported. To the best of our knowledge, this location has not yet been reported in the literature.
| Case report|| |
A 27-year-old male in a state of homelessness with a history of IV drug use was presented to our hospital emergency department. He complained of severe left lower extremity pain that developed over the past 3 days. On the day of presentation, the patient stated that his leg became much more painful, red, and swollen. These symptoms were associated with intermittent high-grade fevers. The patient denied any new trauma in his legs and had no history of diabetes mellitus.
His previous medical history of the patient was only significant for IV drug use. He admitted injecting some heroin into a vein in his left ankle 3 days ago. A review of systems was obtained and disclosed no additional symptoms. He reported using heroin, methamphetamine, and cannabis on a daily basis. The patient denied any use of tobacco and alcohol. His family history was noncontributory. The physical examination revealed that the patient was in acute distress. His body temperature was 40°C. Head-and-neck examination showed no palpable lymphadenopathy or point tenderness.
Heart and lung examination revealed no abnormal findings. His abdomen was soft, nontender, and nondistended. The left lower extremity examination revealed an area of erythema extending from the medial aspect of the left leg reaching up to the left thigh. Neurological examination including cranial nerve examination was unremarkable. Laboratory data obtained at admission revealed a white blood cell (WBC) count of 14.0 × 109/mm3 with 88% neutrophils, hemoglobin of 12.6 g/dL, lactate of 4 mmol/L, and serum sodium and creatinine level of 133 mEq/L and 1.24 mg/dL, respectively. His serological tests were found to be positive for hepatitis C infection. Chest radiography revealed no evidence of pneumonia and no cardiomegaly. The left lower extremity duplex ultrasound (US) revealed evidence of superficial venous thrombosis involving proximal, mid, and distal thigh, as well as proximal calf great saphenous. There was no evidence of deep venous thrombosis. Blood cultures, 3 days after admission, grew F. necrophorum. Computed tomography scan and US of the lower extremity were both negative for any signs of abscess.
Empirical antibiotic treatment with intravenous vancomycin 15 mg/kg/day and piperacillin/tazobactam 3.375 mg every 8 h was initiated in the emergency room. The patient was subsequently admitted to the inpatient medical service in our hospital for further evaluation and management of severe sepsis secondary to extensive suppurative thrombophlebitis. Infectious disease service was consulted and his antibiotics were narrowed to a continuous infusion of ampicillin 2 g/24 h based on blood culture and susceptibility results. The appearance of cellulitis gradually improved. The apparent source of infection was from intravenous drug use where the patient had shot up near the ankle. No additional infectious source was found. A peripherally inserted central catheter was placed to continue IV ampicillin 2 g/24 h infusion for 2 weeks followed by another 2 weeks of 875 mg oral amoxicillin administration at every 12 h.
At the follow-up, after 3 weeks, the patient reported significant improvement in his symptoms. Lower extremity duplex US 3 months later revealed resolving suppurative thrombophlebitis.
| Discussion|| |
F. necrophorum is the normal flora of oropharyngeal cavities in both animals and humans. It is an obligate anaerobic bacterium which may lead to potentially distressing suppurative infections. F. necrophorum is normally associated with Lemierre's disease, characterized by tonsillitis and thrombosis of internal jugular veins., Peripheral vein suppurative thrombophlebitis occurs more frequently in the setting of peripherally inserted catheters or intravenous drug use. The most common pathogen reported among this population is Staphylococcus aureus, Streptococci, and Enterobacteriaceae.,
In the present case report, we reported a unique case of suppurative thrombophlebitis in the setting of intravenous drug use that involves a great saphenous vein of the lower extremity caused by an inhabitant of the oral cavity. Some intravenous drug users have ritualistic practices where they lick their needles before injection in an attempt to enjoy the taste of the drug. This poor hygiene habit puts them at increased risk for acquiring skin and soft-tissue infections caused by oropharyngeal flora. Fusobacterium is usually sensitive to penicillin, but then failure of penicillin and beta-lactamase production by Fusobacterium was also reported. The empiric therapy of neck-and-head thrombophlebitis includes beta-lactam with a beta-lactamase inhibitor such as ticarcillin–clavulanate, piperacillin–tazobactam, ampicillin–sulbactam, or carbapenem monotherapy. On the other hand, empiric therapy of peripheral vein suppurative thrombophlebitis typically includes an anti-staphylococcal agent such as vancomycin with an agent covering Enterobacteriaceae such as ceftriaxone. However, our patient was found to have superficial vein thrombophlebitis caused by Fusobacterium species which is an uncommon anatomical location for this pathogen.
Antibiotic spectrum is then narrowed down based on culture and susceptibility results. The antibiotic therapy duration is not clear. Usually, the patient having superficial thrombophlebitis receives 2 weeks of antibiotics intravenously followed by an additional course of oral antibiotics. The role of anticoagulation in the treatment of superficial vein thrombophlebitis remains controversial. There are no controlled studies available. Some authors suggested anticoagulation only if there is evidence for the extension of thrombus.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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