Septic pelvic thrombophlebitis due to staphylococcus aureus.
Article Type: Case study
Subject: Thrombophlebitis (Diagnosis)
Thrombophlebitis (Care and treatment)
Thrombophlebitis (Case studies)
Thrombophlebitis (Risk factors)
Staphylococcus aureus infections (Complications and side effects)
Staphylococcus aureus infections (Case studies)
Authors: Mostafavifar, A. Mehran
Guilfoose, John
Sarwari, Arif R.
Pub Date: 05/01/2009
Publication: Name: West Virginia Medical Journal Publisher: West Virginia State Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 West Virginia State Medical Association ISSN: 0043-3284
Issue: Date: May-June, 2009 Source Volume: 105 Source Issue: 3
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 204075136
Full Text: Introduction

We present a case of a 30-year-old white female in prior good health, who developed post partum septic pelvic thrombophlebitis with Staphylococcus aureus bacteremia.

Septic pelvic thrombophlebitis (SPT) may take one of two forms; Ovarian vein thrombosis or deep septic pelvic thrombophlebitis. Ovarian vein thrombosis causes a syndrome of acute abdominal pain, fever, a "rope like" tender palpable mass on the affected side, with a leukocytosis. It is relatively amenable to diagnosis by current imaging techniques (1). Deep septic pelvic thrombophlebitis causes high spiking fevers despite antibiotic therapy and is rarely confirmed by imaging techniques. Defervescence usually occurs in response to anticoagulant therapy within 48 hours (1,2). Septic pelvic thrombophlebitis occurs almost exclusively after pelvic procedures such as cesarean section, hysterectomy, and vaginal deliveries. The postpartum state amply fulfills Virchow's triad of factors disposing to thrombosis: hypercoagulability, vein wall changes, and venous stasis (3). The diameter of the ovarian veins increases during pregnancy from 9 to 26mm, and venous pressure is quite low (4). Septic pelvic thrombophlebitis is rare, occurring in 1 of 569 deliveries in one series and 1 in 2000 deliveries in another (5,6). Incidence is higher with cesarean section because of the increased occurrence of endometritis following cesarean sections. Blood cultures may remain negative.

There are no diagnostic gold standards with regards to imaging. Computerized Tomography (CT) and Magnetic Resonance Imaging (MRI) seem to have high and equal accuracy in the diagnosis of ovarian vein thrombosis (7). However, no currently available imaging technique has any claim to accuracy in the diagnosis of deep septic pelvic thrombophlebitis. Patients with SPT are treated with broad spectrum antibiotics that are usually discontinued before the patient is discharged (8). Most experts recommend the use of heparin which is usually discontinued soon after resolution of fever (2).

Case Report

A 30-year-old white female in prior good health was admitted for preterm labor with triplets at 23 weeks gestation. Her early hospital course (first 2-3 weeks) was complicated by bacterial/ fungal vaginosis, superficial thrombophlebitis from a peripheral IV site (no central lines), urinary tract infection, and sinusitis all treated successfully. She had been on Lovenox 40mg qd for deep vein thrombosis prophylaxis. After a prolonged hospital stay she eventually delivered at 29 weeks gestation by elective low transverse cesarean section. Within 48 hours, the patient began having fever, chills, diffuse abdominal pain, dysuria, and low back pain. She remained hemodynamically stable with a leukocytosis of 17.2 x 10^3/ml and no bands. Her maximum temperature was 39.9 degrees Celsius. She did not appear toxic and there were no significant findings on examination of the breasts, lungs, and costovertebral region. She had mild erythema and induration around the incision but no pus or drainage. She was started on an antibiotic regimen of Ampicillin, Gentamicin, and Clindamycin but fever persisted. Computerized Tomography of chest/abdomen/ pelvis with contrast showed that some of the pelvic vessels appeared congested. The urine culture grew Ampicillin susceptible Enterococcus faecalis. Her dysuria improved but fever and other symptoms persisted. Lovenox 90mg bid was started and the patient became afebrile. Her blood cultures returned positive for Oxacillin sensitive Staphylococcus aureus in two separate aerobic bottles from different sites on different days. Antibiotic coverage was narrowed to Nafcillin and Ertapenem and the patient improved clinically with subsequent documentation of negative blood cultures. She was discharged home with a new peripherally inserted central catheter for 6 weeks of antibiotics and two weeks of Lovenox. Unfortunately, one of the triplets died and another developed Staphylococcus aureus bacteremia.

Discussion

This case reports on the association between Staphylococcus aureus bacteremia and deep septic pelvic thrombophlebitis in a post partum patient. As previously described, deep SPT is rarely confirmed by imaging techniques, but the high fever usually responds to anticoagulation within 48 hours (9). The fact that this patient's Staphylococcus aureus bacteremia was identified on two different blood culture sets from two different sites and on different days suggests its association with the patients SPT, likely as an initial endometritis. The pathogenesis of SPT usually involves spread of a pelvic infection, typically in a puerperal woman, into the walls of pelvic veins, causing thrombosis, and subsequent infection of the thrombus (10). While the demonstration of ovarian vein thrombosis by CT is reasonably reliable, false negative results with imaging studies are very common with deep SPT (7). Hence, the diagnosis of SPT remains clinical.

Staphylococcus aureus has emerged as a major problem in today's healthcare system both in the inpatient and outpatient setting. Currently, patients with SPT are treated with broad spectrum antibiotics with activity against Streptococci, Enterobacteriaceae, and Anaerobes. Clindamycin with Gentamicin is a common regimen and Ampicillin is usually added if Enterococci are suspected. Although some Staphylococcus aureus strains are Clindamycin sensitive, many are resistant. Septic pelvic thrombophlebitis is an obscure disease and most published data comes from old or small case series or reports. Antibiotic management follows the experience of Di Zerega et. al (1979), who determined that response to Clindamycin and Gentamicin in women with endometritis following a cesarean delivery was satisfactory (8). In 1988 Walmer et. al associated failure of the Clindamycin and Gentamicin combination with Enterococcal infection. Thus the addition of Ampicillin was suggested, and these three antibiotics are still used today. One case report on Methicillin resistant Staphylococcus aureus Necrotizing Pneumonia arising from an infected episiotomy site illustrates the role of Staphylococcus aureus as an emerging problem (11). The authors report a case of Methicillin resistant Staphylococcus aureus sepsis and pneumonia in a postpartum patient who developed SPT from an infected episiotomy site. Septic emboli from the thrombosed pelvic veins resulted in necrotizing pneumonia and soft tissue infection. Another study on SPT and Preeclampsia by Isler et. al showed that out of 38 patients with SPT, only 7 had positive blood cultures. Of these, 2 patients had Escherichia coli, and 1 each had Enterobacter, Citrobacter, Group B Streptococcus, Staphylococcus aureus, and Bacteroides (12). Blood cultures usually remain negative, with positive cultures documented among only 3% to 29% of patients with SPT (1,6).

Conclusion

In today's era of growing infections due to Staphylococcus aureus including MRSA, its association with SPT will need to be monitored closely and an empiric regimen including the use of a drug such as Vancomycin instead of Clindamycin may need to be considered.

References

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(4.) Hodgkinson, CP. Physiology of the ovarian veins during pregnancy. Obstetrics and Gynecology 1953; 1:26.

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(8.) Dizerega G, Yonekura L, Roy S, Nakamura RM, Ledger WJ. A comparison of clindamycin-gentamicin and penicillin-gentamicin in the treatment of post-cesarean section endomyometritis. American Journal of Obstetrics and Gynecology 1979; 134(3):238-242.

(9.) Schulman, H, Zatuchni, G. Pelvic thrombophlebitis in the puerperal and postoperative gynecologic patient. American Journal of Obstetrics and Gynecology 1964; 90:1293.

(10.) Dunnihoo DR, Gallaspy JW, Wise RB, Otterson WN. Postpartum ovarian vein thrombophlebitis. Obstetrical and Gynecological Survey 1991; 46(7): 415-427.

(11.) Michael Rotas, MD, Sandra McCalla, MD, Chunhua Liu, MD and Howard Minkoff, MD. Methicillin-Resistant Staphylococcus aureus Necrotizing Pneumonia Arising From an Infected Episiotomy Site. Obstetrics and Gynecology 2007; 110(1):188.

(12.) Christy M. Isler, M.D., Brian K. Rinehart, M.D., Dom A. Terrone, M.D., J. Holt Crews, M.D. Everett F. Magann, M.D., and James N. Martin Jr., M.D. Septic Pelvic Thrombophlebitis and Preeclampsia Are Related Disorders. Hypertension in Pregnancy 2004; 23(1):121-127.

A. Mehran Mostafavifar, MD

John Guilfoose, MD

Arif R. Sarwari, MD

All of the Department of Medicine, West Virginia University
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