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Description
A 48-year-old caucasian woman with a history of trauma was treated for osteomyelitis of the left ankle with ceftriaxone and continuous perfusion of vancomycin through a central venous catheter. After 2 months of therapy, the patient suddenly presented with fever, chills, neck and basithoracic pain. Basic observation revealed tachycardia, without any focus of infection. Extensive thrombophlebitis with gas was diagnosed on a thoracic CT scan (figure 1). The catheter was removed and vancomycin was switched to teicoplanin (administration through a peripheral catheter). The blood cultures (four pairs, incubated for 6 days) remained sterile, as did the culture of the catheter. The symptoms were resolved with curative anticoagulation (stopped at 6 months) only. No control CT was performed. Genetic tests revealed a heterozygous factor V Leiden.
A thoracic CT scan revealing catheter-related (vertical arrow) partial superior vena cava thrombosis and complete innominate vein thrombosis, associated with gas bubbles (horizontal arrow).
Vancomycin is known to cause thrombophlebitis, which frequently occurs when this drug is administered through a peripheral catheter, but not when using a central venous catheter, even if the central venous catheter is a predisposing factor for upper-extremity deep-vein thrombosis.1 2 Presence of gas bubbles in a thrombus is usually associated with septic thrombophlebitis, such as during intraabdominal pylephlebitis or Lemierre's syndrome, owing to intraluminal fermentation of carbohydrates due to anaerobic bacteria.3 In the case presented here, we ruled out the diagnosis of septic thrombophlebitis. This extensive aseptic thrombophlebitis with gas was, at least in part, due to continuous vancomycin therapy. The pathophysiology of gas production remained unclear. Hypercoagulability due to heterozygous factor V Leiden may participate in the thrombus formation, but the increased risk of thrombosis in such patients remains controversial.2
Learning points
Continuous infusion of vancomycin through a central venous catheter could be associated with extensive superior vena cava thrombosis.
Extensive thrombophlebitis induced by vancomycin could be associated with gas, without being septic.
Further studies are required to determine whether heterozygous factor V Leiden facilitates profound thrombophlebitis during vancomycin therapy.
Acknowledgments
We acknowledge Dr Thomas Perpoint, Dr André Boibieux and Dr Agathe Sénéchal who participated in patient care.
Footnotes
Competing interests None.
Patient consent Obtained.