Septic Thrombophlebitis Research Articles

A Case Report of Lemierre’s Syndrome with Multisystem Dysfunction in the Setting of COVID-19 Exposure in a Pediatric Patient

A 17-year-old male with no significant past medical history presented to the emergency department with severe sepsis of unknown etiology. The patient was found to have septic thrombophlebitis of the internal jugular vein with multiorgan dysfunction and septic embolization to both lungs. The patient was also noted to have COVID-19 IgM antibodies and multiple close COVID-19 exposures prior to the patient’s emergency department presentation. Here, we present the prolonged and complicated hospitalization of this patient and a review of this rare but important disease.

692: Septic Shock From Sore Throat? Presentation of Streptococcus anginosus Shock and Lemierre Syndrome

INTRODUCTION: Lemierre syndrome is septic thrombophlebitis of internal jugular vein caused by oropharyngeal or head and neck infections The main causative organism is Fusobacterium necrophorum but rarely other organisms such as Staphylococcus aureus, E coli, streptococci, staphylococci, Klebsiella etc can cause the syndrome as well Members of the Streptococcus Anginosus group are rare causes of Lemierre syndrome with very few pediatric case reports in the literature METHODS: A previously healthy 15-year-old female presented with four days of fever, throat pain, abdominal pain and persistent vomiting and was admitted with septic shock requiring extensive fluid resuscitation and vasopressor support Initial labs included WBC 15 2 x 10 9/ L, CRP 34 9 mg/dL, ESR 78 mm/Hr Review of systems was negative for tampon use Rapid streptococcus probe test, respiratory viral panel, and SARS CoV-2 tests were all negative Clindamycin was added to empiric coverage with concern for toxic shock syndrome Within 24 hours of hospitalization, she developed ARDS requiring non-invasive positive pressure ventilation She continued to complain of worsening throat pain and headache CT scan of the neck revealed extensive thrombosis of the left internal jugular and initial blood culture grew Streptococcus constellatus, a member of the S Anginosus group Antibiotic coverage was switched to piperacillin-tazobactam to cover anaerobic organisms such as Fusobacterium as well as Streptococcus Anginosis Enoxaparin was started Lupus antibodies were transiently positive secondary to infection Following discharge, she received intravenous ceftriaxone via PICC line and oral metronidazole for 3 weeks and then oral levofloxacin and metronidazole for 2 weeks She was followed up regularly to assure clearance of septic thrombi from internal jugular vein after 6 weeks of antithrombotic therapy RESULTS: Lemierre syndrome should be considered a diagnosis for an adolescent with throat pain presenting with shock

Jugular Vein Thrombosis and Anticoagulation Therapy in Lemierre's Syndrome-A Post Hoc Observational and Population-Based Study of 82 Patients.

BackgroundLemierre’s syndrome is typically caused by Fusobacterium necrophorum where an oropharyngeal infection is followed by septic internal jugular vein thrombophlebitis with subsequent septic embolization. Yet, the pathogenesis of septic thrombophlebitis, differences dependent on the presence of jugular vein thrombosis, and the role of anticoagulant therapy are insufficiently understood.MethodsPatients with invasive infection with F. necrophorum and Lemierre’s syndrome who had been investigated for jugular vein thrombosis were included from a previous population-based observational study in Sweden. Medical records were reviewed and compared in patients with and without jugular vein thrombosis. Then, patients with jugular vein thrombosis were compared by exposure to therapeutic, prophylactic, or no anticoagulation. Outcomes examined were thrombosis progression, early or late peripheral septic complications, chronic major sequelae, 30-day mortality, and major bleeding.ResultsFifty-one of 82 (62%) radiologically investigated patients with Lemierre’s syndrome had jugular vein thrombosis. Patients with jugular vein thrombosis had lower platelet levels (median, 76 vs 112 ×109/L; P = .04) on presentation and more days to defervesence (12 vs 7 days; P = .03) yet similar rates of major sequelae and 30-day mortality. No significant differences in outcomes were seen between patients with jugular vein thrombosis exposed to therapeutic, prophylactic, or no anticoagulation therapy, yet study outcomes were rare.ConclusionsPatients with Lemierre’s syndrome with jugular vein thrombosis were more severely affected, yet had similar prognosis. Most patients with jugular vein thrombosis recovered well without therapeutic anticoagulation therapy, though adverse events were similarly rare in anticoagulated patients. The observational design and rarity of study outcomes require cautious interpretation.

CTNI-64. MATRIX REGIMEN FOR NEWLY DIAGNOSED PRIMARY DIFFUSE B-CELL LYMPHOMA OF THE CENTRAL NERVOUS SYSTEM

Abstract We report our experience treating 16 patients with newly diagnosed primary diffuse B-cell lymphoma of the central nervous system with the MATRix regimen as reported by Ferreri, et al in 2016. The median age was 66 years (y); 8 patients were men and 8 were women. Fourteen had cerebral mass lesions, 1 had a paraspinal mass, and 1 leptomeningeal disease. Treatment consisted of 4 cycles of rituximab 375 mg/sq m (Days 1, 6); methotrexate 3.5 g/sq m (Day 2); cytarabine 2 g/sq m every 12 h (Days 3, 4); and thiotepa 30 mg/sq m (Day 5). Patients without disease progression received carmustine 400 mg/sq m and thiotepa 4 X 5 mg/kg followed by autologous bone marrow transplantation. Four patients were switched to MATRix after 6 cycles of methotrexate and rituximab and received only 2 initial cycles including cytarabine and thiotepa. Overall, 12 patients completed initial chemotherapy. Eleven of these 12 went on to transplantation; one patient had early disease progression and did not proceed to transplantation. All 4 patients over 70 y died early after 1–2 cycles; the median age of these was 80 y, and the causes of early death were neutropenic fever, septic thrombophlebitis, and cardiac arrest. One patient who completed the entire regimen including transplantation died of fungal pneumonia; the other 11 experienced no serious acute toxicity. One patient had late disease progression; one developed symptomatic leukoencephalopathy. Nine of the 16 patients remain alive. At a median follow-up of 23 months, median time to progression was 421 days and overall survival 564 days. These preliminary data suggest that the MATRix regimen in safe and highly effective in the newly diagnosed setting. However, the high incidence of early death in patients over 70 y suggests that the regimen may be too toxic for elderly individuals.

Limb Transplantation Following Ex Vivo Normothermic Perfusion in an Orthotopic Forelimb Swine Transplantation Model

PURPOSE: Ischemia-reperfusion injury remains a major limiting factor for limb replantation and transplantation. Ex-vivo normothermic limb perfusion has been proven to preserve viability and function of amputated limbs longer than cold storage. Our aim was to investigate the feastibility of limb transplantation following EVNLP and possible vascular, inflammatory and infectious complications in a mid-humerus porcine forelimb transplant model. METHODS: Eight Yucatan miniature pigs, 4 donors and 4 recipients, were used. Right forelimbs of donor animals were amputated at mid-humeral level, to maintain integrity of forearm fascial compartments, and preserved with EVNLP until replantation. The right forelimb of the recipient animal was amputated, and a central venous line was placed in the contralateral neck. Perfusate electrolytes, gases, O2 saturation, muscle contractility, surface temperature (infrared thermography), and peripheral perfusion (indocyanine green agiography) were assessed during EVNLP. The humerus was fixed with a single 3.5 mm LC-DCP plate; microsurgical anastomosis of the brachial artery, cephalic vein, and repair of radial, ulnar, and median nerves were performed under an operative microscope. Tendons of the biceps and triceps were repaired with pulvertaft weave technique. The first animal did not receive systemic immunosuppression. Systemic immunosuppression for the remaining 3 pigs included induction with antithymoglobulin, followed by daily cyclosporine (CSA), mycophenolate mofetil, and methylprednisolone. CSA trough levels were measured daily. Limbs were monitored clinically and histologically for signs of rejection. Bone healing was confirmed with CT scan at euthanasia. The endpoint of the study was 90 days. RESULTS: Warm ischemia time during limb procurement was 20.6 ± 9 minutes and 2.2 ± 0.25 hours during limb transplantation. EVNLP lasted an average of 4.3 ± 0.52 hours. Total time to revascularize was 6.8 ± 0.5 hours. PO2, pH, and lactate were 557 ± 72 mm Hg, 7.5 ± 0.1, 5.6 ± 0.9 mmol/L, respectively. Muscle contractions were 4/5 during EVNLP. All forelimbs were successfully transplanted with no vascular failure. CSA trough levels were on average 678 ± 450, 369 ± 445, and 336 ± 468 ng/ml. Animals 2, 3, and 4 developed septic thrombophlebitis of the central line, which was replaced on POD 14, 51, and 28. Animals 3 and 4 lost IV access on POD 54 and 64, respectively, and were transitioned to PO medications. The first transplanted limb (animal 1) showed evidence of acute rejection on POD 4 and the animal was euthanized on POD 6. In the remaining animals, the incisions healed and initial edema resolved by day 14.The third animal developed angioinvasive aspergillosis on POD 20 with 2 areas of full thickness skin necrosis of trunk. Voriconazol was started and the lesions were resected on POD 51. The animal lost the central line on POD 55, showed evidence of rejection on POD 57 and was euthanized on POD 60. Animals 2–4 showed bone healing and consolidation with the presence of bony callus on CT scans. At endpoint, animals 2 and 4 had reached complete weight bearing on the transplanted limb, at the hoof and wrist, respectively. CONCLUSION: Extremity transplantation can be successfully performed following EVNLP. EVNLP does not increase the risk of vascular or infectious complications. The mid-humerus porcine transplantation model is feasible and reproducible.

ATYPICAL PRESENTATION OF LEMIERRE'S SYNDROME WITH ISOLATED INVOLVEMENT OF THE EXTERNAL JUGULAR VEIN

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Lemierre’s syndrome is a life-threatening complication of pharyngitis leading to internal jugular vein (IJV) thrombophlebitis with pulmonary septic embolisation. Isolated external jugular vein (EJV) thrombophlebitis is rare. CASE PRESENTATION: A 35-year-old woman presented with one day of acute pleuritic chest pain. She had fever, chills, throat pain, dysphagia, malaise, and headache for 2 weeks. On presentation, she had trismus, extensive tender cervical lymphadenopathy with swelling on the left side of the neck, erythematous posterior pharynx and left enlarged erythematous tonsillar pillars without exudates. Blood showed leucocytosis with neutrophil predominance, elevated D-dimer, CRP, elevated bilirubin with normal liver enzymes, low platelets, low albumin, and blood culture revealed Fusobacterium necrophorum. Contrast CT scan soft tissue of the neck showed left tonsillar pillar enlargement with micro-abscesses and extension of inflammation into the left submandibular, parotid, and cervical space with thrombosis of the left EJV. Extension of inflammation into the retro-pharyngeal space was noted. CT Angiogram of Chest revealed bilateral peripheral opacities with cavitation in the right upper lobe and left lower lobe consistent with septic emboli. IJV revealed no thrombosis. A diagnosis of Lemierre’s syndrome was made. The patient improved on antibiotic therapy. DISCUSSION: Lemierre’s syndrome is a rare potentially lethal complication of oropharyngeal infection occurring mainly in young adults characterised by septic thrombophlebitis of the IJV with embolisation to lungs. It is rare (3.6 cases/million/year) with a mortality rate of >15%. 1,2. The common causative organisms are anaerobic gram-negative bacilli from the genus Fusobacterium mainly F. necrophorum.3 The oropharyngeal infection spreads to IJV from local oropharyngeal veins. Lymphatic spread and direct extension of infection also occur. However, in some patients, the venous drainage allows direct propagation of thrombophlebitis into the EJV.3 Patients present with fever, sore throat, neck swelling, pleuritic chest pain with cervical lymphadenopathy. Leucocytosis, elevated ESR, CRP, bilirubin and thrombophilia are seen. CT scan of the soft tissue of the neck and chest with contrast is required for diagnosis. CONCLUSIONS: In patients with severe pharyngitis and pulmonary septic emboli Lemierre’s syndrome must be suspected and the venous system of the neck should be closely visualised for evidence of thrombophlebitis of both IJV and EJV. Reference #1: Nall RW. Sore Throat. In: Stern SC, Cifu AS, Altkorn D. eds. Symptom to Diagnosis: An Evidence-Based Guide, 4e New York, NY: McGraw-Hill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2715§ionid=228250877. Accessed May 28, 2020.2. Reference #2: Barlam TF, Kasper DL. Approach to the Acutely Ill Infected Febrile Patient. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 20e New York, NY: McGraw-Hill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2129§ionid=183880456. Accessed May 28, 2020 Reference #3: Format:Reicher J, Brooke S, Arnold D, Counter P, Abdelgalil A. An unusual case of cavitating pulmonary nodules: Lemierre's syndrome with isolated involvement of the external jugular vein. BJR Case Rep. 2018;4(3):20170093. Published 2018 Feb 22. doi:10.1259/bjrcr.20170093 DISCLOSURES: No relevant relationships by Anomadarshi Barua, source=Web Response No relevant relationships by padmanabhan krishnan, source=Web Response No relevant relationships by Litty Mathews, source=Web Response No relevant relationships by Qasim Sheikh, source=Web Response No relevant relationships by Sarita Singh, source=Web Response

A Novel Account of the 'Forgotten Disease'

Introduction
 Septic thrombophlebitis of Internal Jugular Vein (IJV) secondary to head neck infection, demonstrated by Lemierre in 1936, is a rare although known entity.
 Case Report
 A 35 year old known diabetic female patient presented in the ENT OPDwith complaints of excruciating pain and swelling on the left side of theneck for past three weeks. A tender neck mass of around 8cm x 5cm inthe left side of neck along the anterior border of sternocleidomastoid waspalpable. A computed tomographic (CT) scan of neck revealed a thrombosed left internal jugular vein along with adjoining left sided level 2 and 3 suppurative cervical lymphadenopathy. She was treated conservatively with broad spectrum antibiotics and the patient improved after prolonged treatment. 
 Discussion
 Lemierre syndrome has been appropriately termed as a forgotten disease. This has been an important cause of missed cases. High suspicion of IJV thrombosis in head neck infections, more so in the oropharyngeal infection is the key to diagnosis.

A Rare Case Report of Lemierre Syndrome from the Anterior Jugular Vein.

IntroductionLemierre syndrome is a rare, potentially fatal, septic thrombophlebitis of the internal jugular vein. Treatment includes intravenous antibiotics for Fusobacterium necrophorum, the most common pathogen, as well as consideration for anticoagulation therapy.Case ReportA 27-year-old female presented with left-sided neck swelling and erythema. Computed tomography noted left anterior jugular vein thrombophlebitis and multiple cavitating foci, consistent with septic emboli. We report a rare case of Lemierre syndrome in which the thrombus was found in the anterior jugular vein, as opposed to the much larger internal jugular vein more traditionally associated with creating septic emboli.ConclusionBased on an individual’s clinical symptoms, history, and radiologic findings, it is important for physicians to consider Lemierre syndrome in the differential diagnosis, as the condition may rapidly progress to septic shock and death if not treated promptly. The use of anticoagulation therapy remains controversial, and there is a lack of established standard care because the syndrome is so rare.

Head, Neck, and Abdominopelvic Septic Thrombophlebitis: Current Evidence and Challenges in Diagnosis and Treatment.

Septic thrombophlebitis (STP) is a complex, cross-disciplinary clinical condition that combines a localized infection with a neighboring venous thrombosis. STP can occur at several possible anatomic sites, such as dural sinuses, jugular vein (Lemierre syndrome), portal vein (pylephlebitis), and pelvic veins. Its high mortality in the preantibiotic era improved considerably with the introduction of modern antibiotics. However, little evidence exists to date to guide its clinical management. The incidence of STP or its risk factors may be increasing, and its mortality may still be considerable. These trends would have far-reaching implications, especially in the setting of increasing resistance to antimicrobial agents. No clinical assessment tools exist to support patient screening or guide treatment in STP. Few interventional studies exist on the efficacy and safety of anticoagulation. Recommendations on its indications, duration, and the agents of choice are mostly based on evidence derived from small observational studies. While all forms of STP pose similar challenges, future research may benefit from the distinction between bacteria-associated, virus-associated, and mycosis-associated thrombophlebitis. Addressing these gaps in evidence would enhance our ability to diagnose this condition and treat patients effectively.

Syndrome de Lemierre inversé : à propos d’un cas et revue de la littérature

IntroductionLemierre's syndrome is defined as an oropharyngeal infection due to Fusobacterium necrophorum, associated with septic thrombophlebitis of the internal jugular vein. The uncommon pelvic variant of the syndrome is a rare condition, poorly described in literature. Case reportWe report a case of gynecological Lemierre's syndrome in a 19-year-old woman after a first sexual intercourse, who presented acute respiratory failure, left internal iliac vein thrombosis with pulmonary embolism, in the setting of salpingitis and F. necrophorum bacteriemia. ConclusionGynecological Lemierre's syndrome is a rare and unrecognized condition, which could be lethal. Early recognition of the disorder enables initiation of appropriate antibiotic therapy for 4 to 6 weeks, and discussion of anticoagulant therapy which indications are not yet well defined.

Anaerobic Necrotizing Pneumonia: Another Potential Life-threatening Complication of Vaping?

An adolescent girl with a history of frequent electronic cigarette use of nicotine was hospitalized with severe necrotizing pneumonia. Blood cultures obtained before the administration of empirical broad-spectrum intravenous antibiotics had positive results for the growth of Fusobacterium necrophorum The pathogen is an uncommon but well-known cause of anaerobic pneumonia with unique features that are collectively referred to as Lemierre syndrome or postanginal sepsis. The syndrome begins as a pharyngeal infection. Untreated, the infection progresses to involve the ipsilateral internal jugular vein, resulting in septic thrombophlebitis with direct spread from the neck to the lungs causing multifocal necrotizing pneumonia. The teenager we present in this report had neither a preceding pharyngeal infection nor Doppler ultrasonographic evidence for the presence of deep neck vein thrombi, leading us to explore alternative mechanisms for her pneumonia. We propose the possibility that her behavior of frequent vaping led to sufficient pharyngeal irritation such that F necrophorum colonizing her oropharynx was inhaled directly into her lungs during electronic cigarette use. Preexisting, but not yet recognized, vaping-related lung injury may have also contributed to her risk of developing the infection. The patient was hospitalized for 10 days. At follow-up one month later, she still became short of breath with minimal exertion.

Lemierre's syndrome: A rare complication of otitis media

Lemierre's syndrome, also known as septic internal jugular vein thrombophlebitis, is an extremely rare complication of chronic otitis media, which can be fatal if not managed on time. A 28-year-old female presented to us with left sided otorrhea lasting from 1 month, headache, fever with chills and rigors since 10 days. This was accompanied by torticollis and tenderness along the course of the left internal jugular vein. Otological examination revealed features of chronic suppurative otitis media squamosal type. Computerized tomography revealed features of an occluding thrombophlebitis of the left internal jugular vein up to the left brachiocephalic vein. We performed a canal wall down mastoidectomy for the left ear. The internal jugular vein was not ligated. Patient recovered well after the surgery.

Lemierre’s Syndrome: A Case Report of a Child With Partial Treatment of Streptococcal Pharyngitis

Lemierr e’s syndrome (LS) is a complication of acute oropharyngeal infections leading to septic thrombophlebitis of the internal jugular vein. Since initial discovery, the incidence of LS has decreased due to development of modern antibiotics. In our case report, a child with partially treated streptococcal pharyngitis presented with neck pain, neck swelling and limited range of motion of her neck. Although the patient was well appearing and with an atypical presentation of LS, the diagnosis of LS was confirmed with a computed tomography (CT). As a result, appropriate treatment was quickly initiated to prevent further complication and provide a favorable outcome for the patient. Typical presenting symptoms of LS include fever, dysphagia, neck pain and arthralgia that should lead to the ordering of appropriate laboratory studies and imaging. CT imaging aids in both the diagnosis and management of LS. The use of anticoagulation therapy remains controversial in the management of LS. In addition, there are no generalized guidelines for the treatment of LS, but antibiotic therapy directed at anaerobic coverage can significantly reduce morbidity and mortality in otherwise healthy children. Due to potentially fatal complications, it is crucial to keep LS on the differential diagnosis list in pediatric patients with fever, neck pain, neck swelling, or dysphagia in the week following an oropharyngeal infection. Int J Clin Pediatr. 2020;9(1):4-8 doi: https://doi.org/10.14740/ijcp347

Septični tromboflebitis sigmoidnog sinusa usled hroničnog mastoiditisa i upale srednjeg uva - prikaz slučaja

Sigmoid sinus septic thrombosis is an infrequent complaint that may lead to extensive morbidity and mortality. We report a case with septic thrombosis of the sigmoid sinus caused by chronic mastoiditis and otitis media. A 29-year-old male presented with a 14-day history of tinnitus and true vertigo with a gradually developing swelling on the right side of the neck. Neck computerized tomography (CT) scan found a mastoid abscess. Also, magnetic resonance imaging (MRI) showed an enlargement of the sigmoid sinus veins that was characteristic of septic thrombophlebitis (SSST). The patient's condition and his symptoms and signs improved under antibiotic therapy and his mastoid mass size decreased gradually. In sigmoid sinus septic thrombosis, timely diagnosis and quick management, using broad-spectrum intravenous antibiotics, are critical for case recovery.

Extra-cardiac endovascular infections in the critically ill.

Vascular infections are associated with high complication rates and mortality. While there is an extensive body of literature surrounding cardiac infections including endocarditis, this is less so the case for other endovascular infections. The objective of this narrative review is to summarize the epidemiology, clinical features, and selected management of severe vascular infections exclusive of those involving the heart. Endovascular infections may involve either the arterial or venous vasculature and may arise in native vessels or secondary to implanted devices. Management is complex and requires multi-disciplinary involvement from the outset. Infective arteritis or device-related arterial infection involves removal of the infected tissue or device. In cases where complete excision is not possible, prolonged courses of antimicrobials are required. Serious infections associated with the venous system include septic thrombophlebitis of the internal jugular and other deep veins, and intracranial/venous sinuses. Source control is of paramount importance in these cases with adjunctive antimicrobial therapy. The role of anticoagulation is controversial although recommended in the absence of contraindications. An improved understanding of the management of these infections, and thus improved patient outcomes, requires multi-center, international collaboration.

Lemierre syndrome caused by Klebsiella pneumoniae complicated by epidural abscess - Case report.

Klebsiella pneumoniae is an extremely rare case of the Lemierre syndrome, which is characterized as septic thrombophlebitis of the jugular vein as a consequence of oropharyngeal infection. We present a unique case of Lemierre syndrome caused by Klebsiella pneumoniae, complicated by epidural abscess. The patient presented with fever, severe nuchal pain and stiffness and mild sore throat and headache. Computed tomography revealed a neck abscess localized dorsally to a left mandibular ramus and continuing caudally along the sternocleidomastoid muscle, thrombosis of the left internal jugular vein and fluid collection in the epidural space. Viewed under magnetic resonance imagining, the effusion had the character of an epidural abscess. Cultivation of oropharyngeal swab and blood cultures revealed Klebsiella pneumoniae. The neck abscess was surgically drained, and the patient was treated with a combination of parenteral antimicrobials until complete clinical and radiologic remission. This case highlights the importance of also covering the gram-negative facultative anaerobic rod spectrum in the empiric antimicrobial treatment of Lemierre syndrome.

762. Integrating Diagnostics of Tomorrow into Clinical Practice Today: One Infectious Disease Group’s First 90 Days Experience with the Karius® Test

BackgroundInfection disease (ID) groups covering inpatient and office, antimicrobial stewardship, and infection prevention duties may welcome an opportunity to streamline diagnostics via metagenomic next-generation sequencing (NGS). But the appropriate patient profile for NGS has yet to be defined. In 2019, we began using the Karius Test (KT), an NGS test that identifies and quantifies microbial cell-free DNA in plasma.MethodsOn January 10, 2019 our ID group (7 MDs and an APN covering 14 Illinois hospitals) began using the KT (Redwood City, CA). 5 ml of whole blood is collected, spun to plasma, and shipped to Karius for analysis. Following NGS, human sequences are removed and remaining sequences are aligned to a curated pathogen database of >1,000 organisms. Organisms present above a statistical threshold are quantified in DNA molecules per microliter (MPM) and reported.ResultsOver 90 days 45 KTs were ordered on 42 patients (mean age = 46); including 3 repeat tests. Thirty-six were inpatients (8 in the ICU) with a mean 4.7 days to ID consult and length-of-stay of 16 days. 31% (13/42) were immunocompromised: i.e., transplant, oncology, or HIV/AIDS. Fine needle or open biopsies were performed on 13 patients and 13 patients had bronchoscopy; 30.8% (8/26) were diagnostic of infection. A valid KT result was returned in 44/45 tests (mean 3.5 days from ID consult). 56.8% (25/44) of tests were positive for one or more organisms (a single pathogen was detected on 11 KTs). Among positive tests, 56% (14/25 - 10 bacterial and 4 fungal infections) were confirmed by culture, antigen, or PCR. Mean time to diagnosis for culture, PCR, antigen, and KT was 16.4, 3, 5.5, and 3.5 days, respectively. In 3 cases, the KT was the only positive test but correlated with the clinical scenario resulting in antimicrobial changes (Pneumocystis jirovecii pneumonia in AIDS, pulmonary aspergillosis in AIDS, and Fusobacterium nucleatum septic thrombophlebitis).ConclusionWe identified 4 clinical scenarios where the KT provided value: patients with suspected invasive fungal infections, culture-negative endovascular infections/endocarditis, possible discitis or paravertebral infection, and pulmonary disease in AIDS. Future efforts will include outreach for prevention of invasive diagnostic procedures when a KT is pending or positive.Disclosures All authors: No reported disclosures.

An unusual complication of septic sacroiliitis: Hepatic and splenic infarction after iliac vein thrombosis

Sakroileit genellikle topallama, kalça ve bel bölgesinde yayılan ağrı, ateş gibi non-spesifik semptomlarla prezente olabilir. Ayırıcı tanılar arasında pelvik abse, lumbar disk herniaayonu ve kalçanın septik artriti olup, yanlış tanı oranı yüksektir. Manyetik rezonans görüntüleme sakroiliak eklemden yayılan enfeksiyonun gösterilmesinde oldukça başarılıdır. Bu olgu sunumunda sakroileiti bulunan bir hastada septik trombofilebite bağlı gelişen hepatik ve splenik enfarkt sunulmuştur.

PUNCTURE FROM A TOOTHPICK: AN ATYPICAL PRESENTATION OF PYLEPHLEBITIS

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Septic thrombophlebitis comprises of a spectrum of venous thrombi arising as a sequelae of inflammation in the setting of bacteremia. Pylephlebitis describes a septic thrombophlebitis involving the portal vein. We report a unique case of pylephlebitis resulting from endovascular foreign body perforation of the gastric wall. CASE PRESENTATION: A 69 year old female presented to our Emergency Department with 1 week of progressive abdominal pain, bloating and anorexia complaining of dark stools. She was noted to have sepsis and was started on broad spectrum antibiotics. Workup for sepsis revealed gastric antral thickening (Figure 1). Subsequent esophagogastroduodenoscopy (EGD) showed a toothpick perforating the gastric antral wall (Figure 2). Despite of removal, she continued to have abdominal pain and fever, prompting repeat CT abdomen. It showed infected portal venous, superior mesenteric venous (SMV) thrombus and portal venous gas (Figure 3). Blood cultures grew Streptococcus anginosus and Rothia mucilaginosa. Despite appropriate antibiotics, she developed septic shock and DIC, prompting another CT abdomen revealing a 1.4 cm abscess adjacent to the left anterolateral aspect of the SMV, thrombosis of the left portal vein with extensive portal venous air in the left lobe consistent with septic thrombophlebitis of the superior mesenteric vein and portal venous system (Figure 4). She was taken to OR for exploratory laparotomy, repair of gastric perforation, abdominal abscess drainage, portal vein thrombolysis. She was started on anticoagulation and was given extended course of antibiotic therapy at discharge. DISCUSSION: Pylephlebitis describes a septic thrombophlebitis involving the portal vein. The etiology of pylephlebitis is the pathophysiologic development of localized pockets of inflammation as an humoral immune response to an infection. Thrombophlebitis in small veins either embolize or extend into larger downstream veins, coalescing into the apogee of a portal vein thrombosis. While most cases involve thrombosis involving the SMV (42%), involvement of intrahepatic branches of the portal vein (39%) and the splenic vein (12%) is common. Pylephlebitis may arise from intra-abdominal or pelvic infection through direct downstream sequelae caught in the portal system. While of cases of pylephlebitis occur more commonly in the setting of diverticulitis, pylephlebitis remains a rare complication. Due to the paucity of data regarding pylephlebitis, it is difficult to assert that there is any greater association with extragastric complications when compared to other abdominal disease states. Gastric perforation from tooth pick with secondary pylephlebitis is a very unique clinical presentation. On review of available literature, only one case similar case was found. CONCLUSIONS: Physicians should have a high index of suspicion in cases of intra-abdominal pathology who remain unstable. Reference #1: Kanellopoulou T, Alexopoulou A, Theodossiades G, et al. Pylephlebitis: an overview of non-cirrhotic cases and factors related to outcome. Scand J Infect Dis 2010; 42:804. Reference #2: Plemmons RM, Dooley DP, Longfield RN. Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era. Clin Infect Dis 1995; 21:1114. Reference #3: Peters, Thomas G., et al. “Suppurative Pylephlebitis Caused by Toothpick Perforation.” Southern Medical Journal 1988; 81:414-415. https://doi.org/10.1097/00007611-198803000-00034. DISCLOSURES: No relevant relationships by Krishna Akella, source=Web Response No relevant relationships by Brian Boden, source=Web Response No relevant relationships by Rajeev Fernando, source=Admin input No relevant relationships by Steve Georgopoulos, source=Admin input No relevant relationships by Kashif Hussain, source=Web Response No relevant relationships by Najia Hussain, source=Web Response No relevant relationships by Samer Ibrahim, source=Web Response No relevant relationships by ahsan khan, source=Web Response No relevant relationships by Paul Poidomani, source=Web Response No relevant relationships by Richard Ricca, source=Web Response No relevant relationships by Howard Sklarek, source=Web Response No relevant relationships by Amanda Stashin, source=Web Response

A CASE OF MEDIASTINITS AND SEPTIC THROMBOPHLEBITIS SECONDARY TO SEPTIC STERNOCLAVICULAR JOINT ARTHRITIS

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Septic Sternoclavicular joint (SCJ) is a rare diagnosis. Certain risk factors such as diabetes mellitus have been associated with it. The most serious complication of this condition is mediastinits. CASE PRESENTATION: A 48-year-old male with history of type II diabetes mellitus presented with complaints of a progressively worsening left parasternal discomfort that started 3 days ago, which worsened with movement. He also described subjective fever, chills and diaphoresis at home. He denied upper respiratory symptoms. He has had no recent surgeries or instrumentation. He travelled recently to a but denied sick contacts. On presentation he was febrile, tachycardic, diaphoretic, hypertensive. His labs showed leukocytosis to 32000/mm3, a sodium level of 124 and elevated glucose of 484. On physical examination the patient had reproducible left shoulder and chest wall tenderness with palpation. Levaquin 750 mg intravenously was initiated along with supportive therapy. Computed Tomography (CT) of the chest showed anterior mediastinal fat infiltration consistent with mediastinitis and left sided pleural effusion. CT head and neck was ordered which showed inflammatory changes at the left thoracic inlet with involvement of adjacent mediastinal fat, with nonopacification of left subclavian vein and left innominate vein, suspicious for septic phlebitis and adjacent mediastinitis. Blood cultures grew methicillin-sensitive staphylococci. The patient was then started on cefazolin intravenously. Follow up blood cultures cleared and he was discharged on intravenous cefazolin for 4 weeks and outpatient follow up. DISCUSSION: SJC infection is rare occurring only about 0.5-1% of all infections [1]. Common causes include diabetes mellitus, intravenous drug use, trauma, immunosuppression, infected central lines among others. The clinical signs of SCJ septic arthritis are chest pain localizing to the SCJ (78 %), fever (65 %), and shoulder pain (24 %) and neck pain (2%) [1,2]. Joint swelling and overlying erythema is common. A CT scan of the chest or magnetic resonance imaging is recommended as the initial imaging study that helps identify bone destruction, however the final diagnosis is made from culture of the joint fluid obtained using needle aspiration or open biopsy. Common organisms that has been described are staphylococcus aureus coli, H influenza, Streptococcus pneumonia, streptococcus pyogenes [1,2]. The most potential and serious complication is mediastinitis, which occurs in less than 15% of cases [1,2] as in our case. Our case is unique because it also lead to septic thrombophelibitis of left subclavian vein. Antibiotics with or without drainage and surgical debridement is the treatment of choice. CONCLUSIONS: Sternoclavicular joint septic arthritis is a rare condition. Anterior mediastinitis and septic thrombophlebitis should be suspected as possible complications in uncontrolled diabetes. Reference #1: Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine (Baltimore). 2004;83(3):139-48. Reference #2: 2. Yood RA, Goldenberg DL. Sternoclavicular joint arthritis. Arthritis Rheum. 1980;23:232–9. DISCLOSURES: No relevant relationships by Janak Adhikari, source=Web Response No relevant relationships by Karim Anis, source=Web Response No relevant relationships by AHMET HAKKI KAPICI, source=Web Response No relevant relationships by Fnu Zafrullah, source=Web Response