A case of a flapping infected thrombus in the internal jugular vein, septic pneumonias and heparin‑induced thrombocytopaenia

Česká verze

Authors: P. Majdák ¹; J. Kubík ml. ²; L. Harmátová ³
Authors place of work: Angiologická ambulancia NsP Prievidza so sídlom v Bojniciach, Slovenská republika, vedúci lekár MU Dr. Pavol Majdák ¹; Oddelenie pľúcnych chorôb NsP Prievidza so sídlom v Bojniciach, Slovenská republika, prednosta prim. MU Dr. Jozef Kubík ²; Hematologické oddelenie NsP Prievidza so sídlom v Bojniciach, Slovenská republika, prednosta prim. MU Dr. Livia Harmátová ³
Published in the journal: Vnitř Lék 2011; 57(1): 117-121
Category: Kazuistiky

Summary

We present a case of a 54 years old female patient after anterior wall left ventricular myocardial infarction in 2005 who underwent coronary artery bypass graft (CABG) surgery requiring cannulation of the right internal jugular vein (IJV). She was admitted to a Department of Pulmonary Diseases with left bronchopneumonia (BPN) following 7 day treatment, with hemoptysis, dyspnoea and fevers. Duplex ultrasound (DUS) was used to diagnose flapping thrombus in the right IJV, severe thrombocytopenia and, in addition, progressing multiple infiltrates on X‑ray a few days later. We empirically adjusted the treatment initiated in primary care and observed deterioration of the severe thrombocytopenia during treatment with low molecular weight heparine. We diagnosed heparin‑induced thrombocytopenia (HIT) and, even though this indication was not included in our drug formulary, we initiated treatment with Arixtra (fondaparinux) 2.5 mg s.c. daily. Intensive conservative treatment was associated with significant clinical and laboratory improvement of the condition, significant regression of the IJV thrombus as well as the finding on X‑ray. The final effective antibiotic treatment lasted 20 (amoxicillin + clavulanate) and 10 (clindamycin) days, respectively. Treatment with Arixtra (fondaparinux) continued in primary care and lasted a total of 65 days until normal thrombocyte levels were achieved, with gradual transition to oral anticoagulation treatment. The patient was discharged to primary care on the 23rd day of hospitalization when she was stabilized, afebrile and her cardiopulmonary functions were compensated. We did not identify any case of treatment of jugular thrombosis and concurrent HIT with fondaparin anywhere in the international literature.

Key words:
flapping infected thrombus in the internal jugular vein – septic pneumonia – heparin‑induced thrombocytopenia – fondaparinux

Zdroje

1. Mueller DK, Dacey MJ. Internal Jugular Vein Thrombosis. eMedicine Vascular Surgery. Emedicine.medscape.com/ article/ 461577, Updated: 2009; Sep 21.

2. Jonas N, Fagan J. Internal Jugular Vein Thrombosis: A Case Study And Review of The Literature. www.ispub.com/ The Internet Journal of Otorhinolaryngology 2007; 6: 2.

3. Chlumský J, Havlín J. Idiopatická trombóza jugulární žíly. Prakt Lék 2008; 88: 542– 543.

4. Stern- Sträter J, Hormann K, Neff W et al. Jugularvenenthrombose als paraneoplastisches Syndrom. HNO 2008; 56: 325– 327.

5. Lu MD, Vasavada Z, Tanner C. Lemierre syndrome following oropharyngeal infection: a case series. J Am Board Fam Med 2009; 22: 79– 83.

6. Timsit JF, Farkas JC, Boyer JM et al. Central vein catheter-related thrombosis in intensive care patients: incidence, risk factors, and relationship with catheter-related sepsis. Chest 1998; 114: 207– 213.

7. Wu X, Studer W, Skarvan K et al. High incidence of intravenous thrombi after short-term central venous cathetrization of the internal jugular vein. J Clin Anesth 1999; 11: 482– 485.

8. Ramirez S, Hild TG, Rudolph CN et al. Increased diagnosis of Lemiere syndrome and other Fusobacterium necrophorum infections at a Childrens Hospital. Pediatrics 2003; 112: e380.

9. Syed MI, Baring D, Addidle M et al. Lemierre syndrome: two cases and review. Laryngoscope 2007; 117: 1605– 1610.

10. Leon LR, Patel J, Labropoulos N el al. Excision of Internal Jugular Vein for Catheter- Related Thrombophlebitis. Ann Vasc Surg 2006; 20: 117– 119.

11. Martinez MW, Edson RS. 18- Year- Old Woman With Headache and Sore Throat. Mayo Clin Proc 2004; 79: 231– 234.

12. Salyers WJ, Schnose CH, Zarchan A. No Simple Sore Throat. AMJMED 2007; 120: 860– 862.

13. Kubisz P, Chudý P, Chudej J. Heparínom indukovaná thrombocytopenia – prevencia, diagnostika a liečba. In: Štvrtinová V et al. Venózny tromboembolizmus prevencia, diagnostika a liečba. Bratislava: HERBA 2009: 191– 200.

14. Novotný J. Heparinem indukovaná trombocytopenie – editorial. Vnitř Lék 2005; 51: 148– 152.

15. Hirmerová J. Heparinem indukovaná trombocytopenie u pacientky se stenózou kmene levé věnčité tepny. Vnitř Lék 2005; 51: 231– 237.