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.

[Peculiarities of diagnosis and treatment of varicothrombophlebitis of the lower extremities]

In a vascular surgery clinic there were treated 148 patients, suffering ascending thrombophlebitis--varicothrombophlebitis, in 2009-2010 yrs. Varicose diseases have lasted from 7 to 32 years. Among instrumental methods of investigation there was used ultrasound color angioscanning for diagnosis of varicothrombophlebitis. Flotating thrombus was revealed in 7 (4.7%), juxtawall one--in 73 (49.4%) and the occlusive one--in 68 (45.9%) patients. There were operated on 130 (87.8%) patients, including those in emergency--119 (91.5%). Radical operation was performed in 107 (82.3%) patients.

A case of idiopathic Mondor disease

We report a case of very clinically prominent Mondor disease for which no precipitating etiology could be determined.

[Peculiarities of course of an acute varicose thrombophlebitis in elderly and senile patients and effect of age on tactics of surgical treatment and operative treatment volume]

Examination was conducted in 244 elderly and senile patients (60-89 yrs old), suffering an acute varicosothrombophlebitis (AVTH), of them 240 were operated on. The AVTH course peculiarities were studied up, which influenced the tactics choice and have had determined the indications for surgical intervention performance.

The role of duplex ultrasonography in surgical treatment of acute progressive thrombophlebitis of great saphenous vein

AIM

The aim of this paper was to determine the role of ultrasonographic examination in acute progressive thrombophlebitis (APT) of great saphenous vein (GSV) and its impact in considering indications for urgent surgical treatment. MEHODS: In this retrospective study, out of 141 consecutive patients operated due to APT of GSV above the knee, 63 were examined by ultrasonography prior surgery.

RESULTS

Out of 63 operated patients, in 38 duplex ultrasonography (DUS) revealed that proximal level of phlebitic process was more than 5 cm higher than the one found during physical examination (60.3%). In this group, the mean difference between DUS and clinical finding was 8.5±3.5 cm. In 25 patients there were no differences greater than 5 cm found between DUS and physical examination (39.7%). There was statistically highly significant difference between DUS and physical examination findings (χ2=6.5, P<0.01).

CONCLUSION

This study revealed significant difference between ultrasonographic and physical findings in patients with APT of GSV. DUS presented as reliable diagnostic method in examining, course-following and making decision for operative treatment of these patients.

[Diagnosis of pulmonary embolism]

Nowadays the diagnosis of pulmonary embolism (PE) is based on a "diagnostic strategy" rather than a single test. The first step, after identifying patients with suspicion of PE, is to establish the pre-test clinical probability. Several scores are available to make a standardised and reproducible assessment of the clinical probability and these, therefore, represent valuable diagnostic tools. Indeed, it is the clinical probability that guides further investigation. In patients with low or intermediate clinical probability, PE can be safely ruled out by a negative D-dimer in approximately one-third of patients without additional imaging. In the case of a positive D-dimer or high clinical probability, CT pulmonary angiography is now the recommended imaging technique. However, lower limb venous compression ultrasound and ventilation/perfusion scans remain useful in patients with contraindications to CT; mainly those with renal insufficiency. In the presence of readily available and strongly validated diagnostic strategies, the challenge for the future will probably be better identification of patients in whom PE should be suspected.

Concomitant acute deep venous thrombosis and superficial thrombophlebitis of the lower limbs

INTRODUCTION

Some patients may have deep venous thrombosis (DVT) and superficial thrombophlebitis (ST) of the lower limbs at the same time.

AIMS

To analyze the frequency of risk factors for thrombosis (RF), other than thrombophilias, in patients with concomitant DVT and ST.

PATIENTS AND METHODS

Clinical examination, plasma D-dimers and duplex ultrasonography were performed in 88 consecutive patients (mean age 64.9 +/-13.9 years) admitted in Medical Clinic in 2007. Patients with DVT were divided into two groups: A (with ST - 30 subjects, 34.1%) and B (without ST - 58 patients, 65.9%).

RESULTS

Conditions known as RF were the following (Group A versus B): varicose veins (17 vs 21 patients, p=0.11), obesity (12 vs 19, p=0.66), previous venous thromboembolism (8 vs 16, p=0.87), malignancy (4 vs 10, p=0.44), chronic obstructive lung disease (4 vs 7, p=0.56), sepsis (2 vs 3, p=0.56), stroke and chemotherapy (1 vs 2, p=0.73), bed rest more than three days (1 vs 7, p=0.17), major surgery (1 vs 1, p=0.57), family history of DVT (1 vs 0, p=0.57), immobilizing plaster cast (0 vs 1, p=0.57).

CONCLUSION

One third of patients with DVT had ST. None of those conditions considered as RF for DVT correlated with DVT-ST association.

Mondor's disease of the breast. A retrospective review

BACKGROUND

Mondor's disease is a rare benign clinical entity characterized by thrombophlebitis of the superficial veins of the anterolateral thoraco-abdominal wall. Although several predisposing factors have been reported, the exact pathogenesis remains unclear.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of all patients older than 14 years who were diagnosed with Mondor's disease of the breast at the Breast Cancer Surgery Unit of Army General Hospital over a 3-year period.

RESULTS

Five cases of Mondor's disease were identified among 5717 breast examinations performed during the study period. In 4 patients the disease was considered to be idiopathic. Ultrasonography established the diagnosis in all patients but mammography was inconclusive in two cases due to the presence of dense breast tissue. Four patients received symptomatic treatment. All patients had complete clinical resolution within 2-8 weeks of presentation, and they are well without any evidence of recurrence for 3 to 32 months later. No cases were associated with breast cancer.

CONCLUSIONS

Mondor's disease of the breast is a rare benign self-limiting clinical entity. Ultrasonography is the diagnostic modality of choice but mammography may be inconclusive in the presence of dense breast tissue. Awareness of this rare entity is mandatory to prevent an unnecessary biopsy whereas the patients should be reassured of the benign nature of this disorder. Thorough evaluation is however necessary to rule out an underlying breast cancer or another systemic disease.

Deep vein thrombosis--risks and diagnosis

BACKGROUND

Venous thromboembolism, comprising deep vein thrombosis (DVT) and pulmonary embolism, is common in Australia and is associated with high morbidity.

OBJECTIVE

This article provides a summary of the risk factors for DVT of the lower limb and discusses the diagnosis of the condition using a diagnostic algorithm incorporating clinical assessment, D-dimer testing and imaging studies. It also briefly reviews the clinical significance of isolated distal lower limb DVT and superficial vein thrombosis.

DISCUSSION

Many conditions in the lower limb mimic DVT. Diagnosing DVT on clinical grounds without objective testing is unreliable. Patients incorrectly diagnosed as having DVT may be subjected to unnecessary anticoagulation and its associated risks of bleeding. In contrast, there is a risk of thrombus extension and embolisation when DVT is missed or inappropriately treated.

Compression and walking compared with bed rest in the treatment of proximal deep venous thrombosis during pregnancy

The purpose was to evaluate the benefits of compression and early mobilization in comparison with compression and bed rest in the acute stage of proximal deep venous thrombosis (DVT) in pregnant women.

METHOD

Thirty-two consecutive pregnant women with proximal DVT diagnosed by color duplex ultrasound were divided into two groups. Group A consisted of 15 patients who received elastic compression bandages and early mobilization, and group B including 17 patients with compression bandages and bed rest. All patients received heparin therapy. The clinical characteristics of the two groups were comparable. We assessed the reduction of subjective pain daily with a Visual Analogue Scale (VAS) and the objective pain using Lowenberg test, the reduction of edema was recorded initially and on day 2, 4 and 7. Ultrasound was repeated after seven days.

RESULTS

Resolution of subjective pain was faster during the first three days and near absent at the end of the study period in group A (p < 0.001). Objective pain seriously reduced in group A during the observation period while in group B decreased during the first three days almost by half but remained constantly present over the remaining days (p < 0.001). The same was true for the measurement of leg circumference (p < 0.05). There was no pulmonary embolism and progression of thrombus diameter.

CONCLUSION

Pregnant women with proximal deep vein thrombosis may benefit from leg compression and early mobilization for a faster resolution of the signs and symptoms and this method does not seem to be an additional risk factor for pulmonary embolism.

[Prevention of deep venous thrombosis after knee arthroscopy. Recent advances]

In absence of prophylaxis, the incidence of deep vein thrombosis after knee arthroscopy is reported to be as high as 18%. Recommendations for thromboprophylaxis after knee arthroscopy have actually been updated. The results of the largest randomized clinical trial (KANT study) in this setting are reported together with a review of the literature.

Ultrasound as a complementary diagnostic method in deep vein thrombosis of the leg

The ultrasound method for detection of deep vein thrombosis (DVT) of the leg has been used in a study comprising 47 patients. This method was compared in the same group with a clinical evaluation and was controlled by venography. Clinical evaluation gave a correct diagnosis in 28 (59.6%) of 47 patients, false positive or false negative in 19 (40.4%). With the ultrasound method, the correct diagnosis was made in 41 (87.2%) of 47 patients, false positive in 3 (6.4%) and false negative in 3 (6.4%). No cases were missed of thrombosis situated proximal to the popliteal vein. The method was less accurate in cases of thrombosis situated in or distal of the popliteal vein; the 3 patients in whom a false negative diagnosis was made, belonged to this group. Since the ultrasound method has been shown to give few false positive and false negative results, it should be suitable as a screening procedure in patients with symptoms suggestive of DVT.

The antithrombotic effect of heparin in deep venous thrombosis: relation to four heparin assays

In a prospective study, 280 patients with phlebographically proven deep venous thrombosis received intravenous heparin infusion; 224 of the patients were subjected to control phlebography after 5-8 days of treatment. Females above 70 years showed least phlebographic improvement despite similar heparin dosage and heparin activity. Heparin activity in daily drawn blood samples was determined by four different assays. Chromogenic substrate (CS) assay (Coatest heparin), activated partial thromboplastin time (Cephotest), and thrombin time with recalcified plasma (CaTT) showed weak but significant correlations with thrombus resolution judged by phlebography (p = 0.004, 0.003 and 0.018, respectively). A linear prediction equation showed that the phlebographic result was about equally influenced by the mean dose and by the result of any of the three heparin assays. Thrombin time with citrated plasma showed no correlation. CS assay and CaTT showed significantly lower mean heparin activity in patients with (n = 13) than without clinically diagnosed pulmonary embolism (p = 0.012 and 0.001, respectively).

Streptokinase therapy in the routine management of deep venous thrombosis in the lower extremities. A retrospective study of phlebographic results and therapeutic complications

One hundred and eight patients with phlebographically verified deep venous thrombosis were treated with streptokinase. Total or partial thrombolysis was phlebographically demonstrated in 60 patients (55.6%). Three patients died during treatment, all from pulmonary embolism. Six patients developed clinical signs suggestive of pulmonary embolism. In 16 patients (14.8%), major bleeding complicated the treatment. One patient had anaphylactic shock, while various allergic reactions were recorded in 22. Streptokinase therapy in the routine management of deep venous thrombosis carries an acceptable efficacy and safety similar to what has been achieved under research conditions.

Low specificity of the 125I-fibrinogen uptake test for the diagnosis of deep vein thrombosis in patients with erysipelas of the leg

The 125I-fibrinogen test was evaluated as a diagnostic tool for deep vein thrombosis in patients with erysipelas. In the investigated group of 43 patients, several showed an increased uptake that could not be verified by subsequent phlebography. The false positive test may have been caused by the local inflammatory process. The 125I-fibrinogen test seems to be too unspecific to be used for diagnosing deep vein thrombosis in this patient group.

Diagnosis of deep vein thrombosis with 99Tcm-plasmin

The diagnostic efficiency of 99Tcm-plasmin test was evaluated by X-ray contrast phlebography in 110 consecutive patients with suspected deep vein thrombosis (DVT). The test was positive in 50 of 55 patients with DVT (sensitivity 91%) and negative in 18 of 55 without DVT (specificity 33%). The positive plasmin test in patients without DVT was in most cases due to another inflammatory process or a post-thrombotic state. The 99Tcm-plasmin test is a rapid and sensitive screening method for th diagnosis of DVT, but as it is based on comparison between the legs, it may be unreliable in cases of bilateral thrombosis. The low specificity makes it less valuable in patients with concomitant inflammatory disease or previous thrombosis in either leg. When the plasmin test is positive, the diagnosis of DVT should in most cases be confirmed by X-ray contrast phlebography.