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Key Features

Essentials of Diagnosis

  • Red, painful induration along a superficial vein, usually at the site of a recent intravenous line

  • Marked swelling of the extremity may not occur

General Considerations

  • May occur spontaneously, often in pregnant or postpartum women or in individuals with varicose veins

  • May be associated with

    • Trauma

    • Occult deep venous thrombosis (DVT) (in about 20% of cases)

    • Short-term venous catheterization of superficial arm veins

    • Longer term peripherally inserted central catheter lines

  • May also be a manifestation of systemic hypercoagulability secondary to abdominal cancer

  • Pulmonary emboli are exceedingly rare and occur from an associated DVT

  • Observe intravenous catheter sites daily for signs of local inflammation

Clinical Findings

Symptoms and Signs

  • Dull pain in the region of the involved vein

  • Induration, redness, and tenderness along the course of a vein

  • Process may be localized, or it may involve most of the great saphenous vein and its tributaries

  • Inflammatory reaction generally subsides in 1–2 weeks; a firm cord may remain for much longer

  • Edema of the extremity is uncommon

  • Proximal extension of induration and pain with chills and high fever suggest septic phlebitis

Differential Diagnosis

  • Cellulitis

  • Erythema nodosum

  • Erythema induratum

  • Panniculitis

  • Fibrositis

  • Lymphangitis

  • Deep thrombophlebitis

Diagnosis

Laboratory Tests

  • Blood culture: in septic thrombophlebitis, the causative organism is often Staphylococcus aureus; other organisms, including fungi, may also be responsible

Imaging Studies

  • Ultrasonography to assess extent of thrombosis

Treatment

Medications

  • Nonsteroidal anti-inflammatory drugs

  • For septic thrombophlebitis

    • Antibiotics (eg, vancomycin, 15 mg/kg intravenously every 12 hours plus ceftriaxone, 1 g intravenously every 24 hours); if cultures are positive, continue for 7–10 days or for 4–6 weeks if complicating endocarditis cannot be excluded

    • Systemic anticoagulation with heparin or fondaparinux

  • Prophylactic dose low-molecular-weight heparin or fondaparinux is recommended for superficial thrombophlebitis of the lower limb veins measuring 5 cm or longer

  • Full anticoagulation is reserved for disease that is rapidly progressing or there is concern for extension into the deep system

  • Septic superficial thrombophlebitis requires

    • Urgent treatment with heparin (Table 14–16) to limit additional thrombus formation and antibiotics (eg, vancomycin, 15 mg/kg intravenously every 12 hours plus ceftriaxone, 1 g intravenously every 24 hours)

    • Removal of the offending catheter in catheter-related infections

Table 14–16.Initial anticoagulation for VTE.1

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