[Mondor's disease or systemic sclerosis - diagnostic and therapeutic dilemmas]

In this article we have presented a case of 31-year-old male with thickening of the skin and tender cord of superficial veins of the penis and laboratory findings of the high titer of PM/Scl-100 antibodies in the serum. The patient was referred to the Rheumatology Department due to suspected systemic sclerosis. The HRCT scan of his lungs revealed fibrous degeneration and ground-glass opacity in the lower lobes. Capillaroscopy showed abnormalities, which were not typical for systemic sclerosis. In Doppler ultrasound examination of penis, superficial dorsal and circumflex veins thrombosis and inflammatory infiltration were observed. Taking into account the entire clinical picture, the patient was diagnosed with rare penile Mondor's disease and was under surveillance for systemic sclerosis.

Lesson of the month 1: Spontaneous septic thrombophlebitis presenting with bacteraemia diagnosed by PET-CT scan

Spontaneous septic thrombophlebitis is a rare complication of Staphylococcus aureus bacteraemia. Its true incidence is unknown as septic thrombus is not often considered as a source in the typical 'screen' of tests used to find the source of a bacteraemia.Positron emission tomography computerised tomography (PET-CT) is becoming increasingly available to physicians, is highly sensitive and yields specific anatomical information regarding abnormal metabolically active sites in infection, inflammation and neoplasia.In this case, PET-CT enabled the identification of the source of a septic thrombus and enabled focused management. PET-CT should be considered as part of the raft of tests used to identify an obscure source of fever/bacteraemia.

Mondor's disease of the breast in a Nigerian woman previously treated for invasive ductal carcinoma in the contralateral breast: A case report

Mondor's disease is a self-limiting sclerosing angitis mostly affecting the superficial veins of the breast and chest wall. It is seldom diagnosed, and its etiology and epidemiology are speculative. However, numerous predisposing factors including breast cancer have been postulated. In Nigerian literature, only two cases have been documented to the best of our knowledge. This report is aimed at reminding breast specialists to include it as a diagnostic consideration in patients presenting with a breast lump in the appropriate clinical setting. Its imaging features are also highlighted because it may be incorrectly overlooked as mere ductal dilatation. We present the case of a 60-year-old woman who complained of a painful cordlike lesion in her right breast. Mondor's disease was diagnosed based on the clinical and radiological findings. She had also been previously treated for invasive ductal breast carcinoma in the contralateral breast. Mondor's disease is usually a benign entity, which may resolve spontaneously. On the other hand, it may also be the sole presenting symptom or clue of a breast malignancy; hence, a need for increased awareness.

Necrotizing Lip Infection Causing Septic Thrombophlebitis of the Neck: A Rare Variant of Lemierre Syndrome

Lemierre syndrome is an uncommon condition in which internal jugular vein thrombosis presents after recent oropharyngeal infection. Frequently, this is accompanied by septic emboli. This report outlines a variant of this disease process, with septic thrombophlebitis of the neck associated with a necrotizing skin infection of the lower lip and chin. A 25-year-old man with lower lip and chin swelling, initially managed with intravenous antibiotics, progressed to the development of a left facial vein thrombus, septic emboli to the lungs, and a necrotizing lower lip and chin infection that was managed with debridement, thrombectomy, and prolonged hemodynamic and pulmonary support. A necrotizing skin infection with thrombus of the jugular system and septic emboli is a very rare variant of Lemierre syndrome. Early recognition of an infection with septic emboli and/or necrotizing pathobiological findings allows for prompt antibiotic and surgical therapy, minimizing the mortality of these potentially lethal infections.

Liposomal Heparin Spray: A New Formula in Adjunctive Treatment of Superficial Venous Thrombosis

The objective of this study was to assess the efficacy and safety of liposomal heparin spray—a new formula of topical heparin delivery. This was a randomized, multicenter, controlled open clinical trial with 2 parallel groups. Forty-six outpatients with clinical signs of superficial venous thrombosis (SVT) were treated with either topical liposomal heparin spraygel (LHSG) (Lipohep Forte Spraygel, 4 puffs of 458 IU tid (n=22) or with low-molecular-weight heparin (LMWH) (Clexane 40 mg once a day (n=24), administered subcutaneously (sc). Main outcome measures were efficacy parameters (improvement of local symptoms—pain control and planimetric evaluation of erythema size, duplex Doppler assessment of thrombus regression) and safety parameters (documentation of adverse events, with particular reference to deep vein thrombosis [DVT] by duplex sonography, and patients’ and investigators’ assessment of drug tolerance). Patients’ and investigators’ subjective assessment of efficacy of treatment and change in basic biochemical parameters were defined as secondary outcome measures. Statistical analysis was performed with use of Wilcoxon test, Mann-Whitney U-test and Chi-square test. Regression of SVT-related symptoms, including pain, erythema, and thrombus presence, was shown as comparable in LHSG and LMWH groups. These results were corroborated by efficacy assessment by investigators and patients. Three cases of deep venous thrombosis in heparin spraygel and 1 in heparin sc group were reported. No significant adverse reactions were observed in the spraygel group, but 1 serious allergic reaction was observed in the LMWH group. Tolerance of new formula heparin was assessed as good. Heparin spraygel—a new topical mode of heparin application, seems a promising method of heparin delivery. This initial study has demonstrated comparable efficacy and safety of LHSG and LMWH in local treatment of SVT. These findings should be confirmed by further extensive study that will reach appropriate statistical power to support such conclusion, for despite heparin treatment, significant risk of DVT was demonstrated in both groups.

[Thrombophlebitis in an Elderly Japanese Woman Treated with Tamoxifen for Breast Cancer]

In this study, we report the rare case of an elderly woman who developed thrombophlebitis after being treated with tamoxifen for breast cancer. She visited our department with a lump in her left breast. She underwent core needle biopsy, and she was diagnosed with breast cancer (invasive ductal carcinoma, ER- and PgR-positive, HER2-negative). We chose hormonal therapy because surgical treatment was deemed too invasive considering her general status. She was administered tamoxifen (20 mg/day) instead of an aromatase inhibitor in consideration of her osteoporosis. Six months after initiating tamoxifen therapy, she exhibited swelling in her left leg. Computed tomography and ultrasound revealed thrombophlebitis in her left femoral vein. She stopped taking tamoxifen and started warfarin potassium as thrombolytic therapy, after which thrombophlebitis was relieved. Advanced age may be a risk factor for thrombophlebitis associated with tamoxifen treatment; therefore, precautions should be taken accordingly.

[Thrombotic complications in severe forms of varicose disease: diagnosis, surgical treatment, using miniinvasive methods]

Actual issues of surgical treatment of patients, suffering complications of varicose disease severe forms, are discussed. The causes of unsatisfactory results of treatment of patients, suffering varicothrombophlebitis, the main of which is the absence of common tactics of operative treatment and anticoagulant therapy, were analyzed. There were formatted the groups of patients, suffering severe forms of varicose disease of various localization of thrombotic process, a differentiated tactics of their surgical treatment was proposed.

[Monitoring of the state of the proximal portion of thrombus in conservative treatment of patients with varicothrombophlebitis]

Ultrasound duplex scanning (USD) was used to study dynamics of the state of the proximal portion of the thrombus in patients presenting with acute varicothrombophlebitis of saphenous veins during conservative treatment. We examined a total of fifty-four 29-to-78-year-old (mean age 53.5 years) patients with acute varicothrombophlebitis of saphenous veins, including 15 (27.8%) men and 39 (72.2%) women. USD was used to determine: localization and extent of thrombosis, proximal level of the thrombus, presence of the free portion of the thrombus, density and structure of the proximal and distal portion of the thrombus, thickness of the inflamed venous wall and paravasal fat at the level of the proximal and distal portions of the thrombus. Twelve (22.2%) patients were found to have signs of thrombus flotation with high embologenic risk; these patients underwent the operation of Troyanov-Trendelenburg and were excluded from the study. The remaining 42 patients received conservative treatment and were dynamically followed up by means of USD. All patients on the background of comprehensive conservative treatment showed positive dynamics consisting in decreased mass and density of the thrombus, shift of its proximal border in the distal direction, decreased thickness of the inflamed venous wall and paravasal fat. Two variants of dynamics were singled out: relatively rapid (during a week) - group 1 (n=11) and relatively slow (during one month) - group 2 (n=31). It was determined that the most significant factors promoting rapid lysis of the proximal portion of the thrombus were as follows: the term of seeking medical attention (duration of thrombosis), low echogenicity of the thrombus, cellular pattern of the thrombus and thickness of the paravasal fat. A conclusion was drawn that monitoring of the state of the proximal portion of the thrombus by means of USD makes it possible to maximally approach solving the problem of individualized treatment of patients with thrombosis of saphenous veins.

Spontaneous bacterial coronary sinus septic thrombophlebitis treated successfully medically

A 38-year-old farmer was hospitalized for fever, chills, cough, and chest pain lasting for 7 days. Due to persistent symptoms, patient was referred to hospital. Blood cultures identified oxacillin-sensitive Staphylococcus aureus (OSSA). Transthoracic echocardiography (TTE) showed large pericardial effusion, a mobile heterogeneous mass originating from the coronary sinus ostium, no sign of valvular endocarditis. Pericardiocentesis was done carrying out purulent fluid, microbiological culture isolating an OSSA. Parenteral penicillin M was administered for 6 weeks. At the end of this antibiotherapy regimen, TTE showed no coronary sinus mass with complete vacuity of the coronary sinus vein and no pericardial effusion.

[Surgical treatment tactics for acute varicothrombophlebitis atypical forms]

Changes of phlebohemodynamics under control of ultrasonographic investigation were registered in 237 patients, suffering an acute varicothrombophlebitis (AVTH) of superficial veins of lower extremities (LE). In 21 patients atypical forms of AVTH were revealed, including reflux toward a big subcutaneous vein (BSV) of the leg and/or small subcutaneous vein (SSV); reflux toward insufficient indirect veins on hip and shin; reflux toward insufficient direct perforant veins. For atypical forms of AVTH the urgent operations on hip and shin were performed: crossectomy, short or long stripping, phlebectomy and/or scleroobliteration of tributaries; open subfascial resection (mini-Linton); deferred operations: phlebectomy of the BSV/SSV tributaries, open scleroobliteration, subfascial resection (mini-Linton). Systematization of the AVTH forms in accordance to the LE segments have permitted to determine strategy and tactics of the patients treatment, what have important practical significance.

[Superficial thrombophlebitis of the lower limbs from the surgeons point of view]

INTRODUCTION

A new consensus on the management of superficial thrombophlebitis (STP) from the Central European Vascular Forum (CEVF) for the diagnosis and treatment of STP recommends anticoagulation treatment either with Fondaparinux 2.5 mg for at least 45 days or with low molecular weight heparin (LMWH) for 4 weeks in patients with thrombosis of GSV/SSV proven by duplex ultrasonography (DUS) and with thrombus length exceeding 5 cm. The dosage and duration of anticoagulation treatment depend on the associated diseases and other risk factors for TVE. Many options for doses an duration of treatment are referred to in the literature. Emergency surgery is not recommended. The aim of this study is to demonstrate the role of DUS examination in acute ascending thrombophlebitis (ASTP) of the GSV, and demonstrate the efficiency of surgical treatment - crossectomy and phlebectomy of thrombosed GSV/SSV.

MATERIAL AND METHODS

The authors present their clinical experience with DUS diagnosis and surgical treatment of acute ascending thrombophlebitis in GSV/SSV on 66 patients with 68 operations. In two of them bilateral crossectomy was performed. In the diagnosis it is necessary to perform DUS examination after clinical diagnosis of acute thrombophlebitis. It should be done bilaterally, not only in the affected limb. DUS confirms the measure, progression and eventually ascension of the thrombosis on the trunk of the GSV/SSV and perforating veins. Progress of the thrombotic process from the thigh to the SF/SP junction is usually a matter of a few hours. Daily ultrasound assessment should therefore be performed in acute thrombophlebitis, even during anticoagulation therapy. Thrombus near the SF/SP junction is a reason for urgent surgery - crossectomy and phlebectomy.

RESULTS

66 patients were operated on under general anaesthesia without any complications. A large hematoma in the subinguinal region developed in one patient after surgery. A 50-year-old patient returned with colliquation of the residual varicose vein on the lower leg. Outpatient incision and evacuation had to be performed 3 weeks after surgery. Anticoagulation therapy with warfarin was started in two patients. The other patients were discharged 4 to 6 days following surgery without any problems. Post-operative anti-coagulation in other patients was not longer than 2 weeks.

CONCLUSION

Urgent crossectomy and phlebectomy represent a reliable method of treatment in the management of acute ascending thrombophlebitis of GSV/SSV, guaranteeing prophylaxis of complications, especially in pregnant women with PT in the later phase of pregnancy. Surgical treatment destroys the damaged vein with crossectomy as a potential cause of deep vein thrombosis (DVT), pulmonary embolism (PE) and STP recurrence. After anticoagulation therapy the affected vein remains in situ. It can potentially cause the recurrence of STP, and DVT and PE may develop.

[Management of superficialis thrombophlebitis. Guidelines of the Angiologiy Section of the Slovak Medical Chamber (2013)]

The aim of Guidelines of the Angiology Section of the Slovak Medical Chamber (AS SMC) is to address a last european guidelines for the management of thrombophlebitis superficialis, as well as results in evidence based  medicine (EBM) in order to assess their contribution to our expanding knowledge on rational management of thrombophlebitis superficialis.

DISCUSSION

Superficial thrombophlebitis is a common disease, usually considered to be benign. However, the practice of systemic duplex ultrasonography has revealed a large number of cases of deep vein thrombosis concomitant with superficial thrombophlebitis. Assessment of clinical probability of deep vein thrombosis and venous tromboembolism and systematic duplex ultrasound investigation has been proposed in the initial management of superficial thrombophlebitis, to detect the presence of any underlying deep vein thrombosis. In contrast with extensive information on the management of deep vein thrombosis, there is little knowledge about the most appropriate treatment of the superficial thrombophlebitis.

CONCLUSION

The treatment of superficial thrombophlebitis should improve local symptoms while preventing the development of complications such as venous thromboembolism. The most effective therapeutic approach to superficial thrombophlebitis seems to be represented by fondaparinux (a synthetic selective indirect inhibitor of factor Xa) which have been shown to prevent VTE events and the extension and/ or recurrence of superficial thrombophlebitis.

Pulse-spray treatment of total occlusive jugular venous suppurative thrombophlebitis

A 63-year-old man was diagnosed with jugular venous suppurative thrombophlebitis after undergoing strangulation ileus surgery. His condition was not stabilized by therapy with antibiotics, heparin or other supportive treatments. Pulse-spray treatment (PST) was administered, following which, the patient was afebrile without symptoms and the laboratory data improved. There were no complications such as sustained sepsis, septic embolisms or pulmonary embolisms. This is a unique case report of the use of a pulse-spray catheter in the treatment of total occlusive jugular venous suppurative thrombophlebitis following the failure of medical therapy.

Early ultrasonographic finding of septic thrombophlebitis is the main indicator of central venous catheter removal to reduce infection-related mortality in neutropenic patients with bloodstream infection

BACKGROUND

Septic thrombophlebitis increases patient morbidity and mortality following metastatic infections, pulmonary emboli, and/or septic shock. Central venous catheter (CVC) removal for occult septic thrombophlebitis challenges current strategy in neutropenic patients.

PATIENTS AND METHODS

We prospectively evaluated infection-related mortality in 100 acute leukemia patients, with CVC-related bloodstream infection (CRBSI) after chemotherapy, who systematically underwent ultrasonography to identify the need for catheter removal. Their infection-related mortality was compared with that of a historical cohort of 100 acute leukemia patients, with CRBSI after chemotherapy, managed with a clinically driven strategy. Appropriate antimicrobial therapy was administered in all patients analyzed.

RESULTS

In the prospective series, 30/100 patients required catheter removal for ultrasonography-detected septic thrombophlebitis after 1 median day from BSI onset; 70/100 patients without septic thrombophlebitis retained their CVC. In the historical cohort, 60/100 patients removed the catheter (persistent fever, 40 patients; persistent BSI, 10 patients; or clinically manifest septic thrombophlebitis, 10 patients) after 8 median days from BSI onset; 40/100 patients retained the CVC because they had not clinical findings of complicated infection. At 30 days median follow-up, one patient died for infection in the ultrasonography-assisted group versus 17 patients in the historical cohort (P<0.01). With the ultrasonography-driven strategy, early septic thrombophlebitis detection and prompt CVC removal decrease infection-related mortality, whereas clinically driven strategy leads to inappropriate number, reasons, and timeliness of CVC removal.

CONCLUSION

Ultrasonography is an easy imaging diagnostic tool enabling effective and safe management of patients with acute leukemia and CRBSI.

Ultrasound diagnosis of three cases of Mondor's disease

OBJECTIVE

To describe clinical features and ultrasound findings of three cases of a little-known and relatively infrequent entity in daily clinical activity, which is often unnoticed and under-reported: penile Mondor's disease or superficial penile veins thrombophlebitis.

METHODS

We are reporting the cases of three patients aged 33, 25 and 39 years who were referred to our department, the first case with suspicion of inguinal hernia, the second one to rule out testicular pathology because of pubic and perineal discomfort, and the third one for painful induration of the dorsal region of the penis. The three patients underwent Doppler-ultrasound examination (Toshiba®, using a 13-18MHz linear transducer) to establish definitive diagnosis, and had a favorable evolution with conservative management.

RESULTS

Ultrasound examination revealed: Case 1. Penile superficial dorsal vein and lateral superficial veins thrombosis. Case 2. Thrombosis of the right branch of the superficial dorsal vein and its perineal distal connections. Case 3. Penile superficial dorsal vein thrombosis. Definitive diagnosis of the three cases was Mondor's disease.

CONCLUSIONS

Mondor's disease is an often under-reported entity in daily clinical activity. Doppler-ultrasound findings (echogenic material within veins, lack of any response after compression by the transducer and absence of color flow) confirm de diagnosis. This disease has a favorable evolution and functional prognosis. Knowledge of Mondor's disease by echographists is basic to avoid false-negative results in radiologic examination.