Internal Jugular Vein Thrombosis Research Articles

When a Peripartum Cardiomyopathy Patient Hides Various and Serious Risk Factors for Recurrent and Fatal Thromboembolic Events Even Under Well-Conducted Oral Anticoagulation

Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure that occurs during the final month of pregnancy through about five months after delivery, without any other known cause, and it increases the risk of thromboembolic events by many folds. A 38-year-old female with a history of peripartum dilated cardiomyopathy was admitted to our hospital, one month after a cesarean section, for severe breathlessness. Examination revealed signs of global heart failure and right deep vein thrombosis. Pulmonary CT angiography revealed pulmonary embolism of the right pulmonary artery. The patient was treated by oral anticoagulation with acenocoumarol with all international normalized ratio (INR) values within the target range (2-3). One month later, she was admitted to the emergency department with acute dyspnea and superior vena cava syndrome. Thoracic CT angiogram showed bilateral pulmonary emboli associated with an extensive deep vein thrombosis of both internal jugular veins, sigmoid sinuses, subclavian veins, innominate venous trunks, and the origin of the superior vena cava without any lesion suspected of malignancy. The thrombophilia screen performed six weeks after the suspension of vitamin K antagonists (VKAs) revealed severe deficiencies of protein C and protein S. In this report, we present the first case of recurrence of fatal thromboembolic events under well-conducted oral anticoagulation in a patient with PPCM associated with severe protein C and protein S deficiencies.

Follicular Variant of Papillary Carcinoma Thyroid with Massive Angioinvasion of the Internal Jugular Vein: Our Approach

Follicular variant of papillary carcinoma thyroid is an aggressive variant of papillary carcinoma thyroid. It is more commonly associated with extrathyroidal extension and regional lymphadenopathy. It can rarely be associated with microscopic vascular invasion but tumor thrombus into great veins is a rare phenomenon. We present a case of 60-year-old male with follicular variant of papillary carcinoma thyroid with tumor thrombosis in superior thyroid vein and internal jugular vein (IJV). We report a case of a 60-year-old male who presented with a large swelling in the lower part of left side of neck for 4 months. Clinical examination revealed a hard swelling of 12x8 cm in left side of neck. Ultrasonography showed a solitary thyroid mass of the left lobe and a dilated left superior thyroid vein and ipsilateral IJV. Fine-needle aspiration cytology revealed follicular variant of PTC cells. Total thyroidectomy was done. A tumor thrombus was discovered in the superior thyroid vein and left IJV was found to be dilated. The left IJV with superior thyroid vein was ligated and excised. The patient recovered well after the operation with no local or distant metastasis detected. Follicular variant of PTC commonly spreads to the lymph nodes. Vascular spread via direct intravascular extension through superior thyroid vein is extremely rare. On palpation cord like IJV is felt on the involved side. Neck ultrasound play important role in the diagnosis. Aggressive surgical treatment with IJV ligation above and below the tumor thrombus is recommended to minimize the risk of potentially fatal complications of the intraluminal masses. Intravascular tumor extension into IJV of neck in follicular variant of PTC is rare and can be associated with serious consequences. Total thyroidectomy with thrombectomy with ligation of IJV must be done.

The challenges of a Lemierre’s syndrome in COVID-19 times

<p>Lemierre’s syndrome is a type of necrotizing fasciitis of the head and neck that is an uncommon rapidly spreading infection involving the skin, subcutaneous tissue and the fascia leading to life-threatening complications like septicaemia, bone marrow suppression, disseminated intravascular coagulation and multi-organ failure. The management of this disease, especially in COVID-19 pandemic is a challenge as it is associated with high morbidity. A 46-year-old male presented to us with complaints of swelling in the neck with discoloration of skin in the neck and chest. Computed tomography (CT) scan of the neck revealed thrombosis of the right internal jugular vein (IJV) and diffuse abscesses on both sides of the neck. A high index of suspicion is required for the diagnosis of Lemierre’s syndrome in the absence of typical clinical features. The rapid, unpredictable dissemination of infection and occult thrombus within the IJV make both diagnosis and management a challenge especially, during COVID-19 times.</p>

Internal jugular vein thrombosis and pulmonary thromboembolism after head and neck reconstructive surgery

Free flap failure secondary to internal jugular vein thrombosis (IJVT) is a significant complication after head and neck reconstructive surgery. A consensus has not yet been reached among reconstructive surgeons regarding the treatment of IJVT. We retrospectively evaluated the incidence of IJVT in 118 patients who underwent free flap reconstruction at Hyogo Cancer Center, Akashi, Japan. The occurrence of IJVT-related flap circulation crisis and pulmonary thromboembolism (PTE) was studied. This study was approved by the institutional ethics committee, and written informed consent was obtained from each patient. From 118 patients who underwent head and neck reconstructive surgery, we included 116 internal jugular veins (IJVs) preserved after neck dissection in the present study. IJVT was confirmed in 25 (21.6%) IJVs from 23 patients. One patient (0.8%) developed venous congestion due to IJVT, which resulted in total flap necrosis. Two patients (1.7%) exhibited PTE associated with IJVT. They were treated with direct oral anticoagulants for 3 months and were discharged without any sequelae. Our results suggest that IJVT after head and neck reconstructive surgery caused not only flap circulation crisis but also PTE. Reconstructive surgeons should be aware of the potential risks due to serious complications associated with IJVT.

MMED PROJECT The Clinical Profile of Takayasu Disease at Tygerberg Academic Hospital – a retrospective study

Takayasu’s arteritis (TA) is a disease of unknown etiology that causes chronic inflammation of the large blood vessels and usually involves the aorta and its branches. The inflammatory process initially leads to thickening of the arterial wall and may result in stenosis, occlusion, dilatation or aneurysm formation. Although TA occurs more commonly in certain regions such as Asia, it is a global disease. Currently, there is a dearth of information on this condition in African countries, including South Africa. Results: We have identified 50 patients meeting the ACR criteria for the diagnosis of TA. Data was drawn from the records of the Division of Rheumatology as well as the angiographic records of TA. This included patient demographics, mode of presentation, classification, co-morbidities, complications, clinical and laboratory features, radiological findings, drug therapy as well as outcomes. The cohort comprised 34 of mixed race, 12 black and 4 white patients. The mean age at diagnosis was 16-56 (28.2) years. The most common presention was hypertension, followed by CVA, heart failure, and syncope. Angiography revealed Type V (most of aorta) and Type I (aortic arch branches) lesions to be the most common and that stenosis was much more common than aneurysm formation. Two patients had concomitant antiphospholipid syndrome. Another two had concomitant internal jugular vein thrombosis. Six patients had significant mediastinal lymphadenopathy, only one of whom had TB. Corticosteroids and additional immunosuppressive therapy were used to control disease activity in most patients. Biological treatment was used in two patients. Surgical intervention consisted mainly of renal auto transplantation. Twelve percent of patients had repeated admissions, which included planned surgical intervention. We had two mortalities, both as a result of massive strokes. The mortality rate was 6%. Only 3 patients had active TB. Conclusion: The study revealed gender and age characteristics similar to previous studies, confirming that TA affects mainly young females. The mortality rate of 6% in this cohort is significantly lower than that of previous series. The unusual findings in this study were: Significant chest lymphadenopathy in 12% of the cases,the significantly lower percentage of active TB of only 6%, two cases of a rare finding of venous thrombosis as well as 2 cases of an uncommon finding in TA of antiphospholipid syndrome.

Abstract 14357: Straight for the Jugular: Cardiomyopathy After Recent EBV Infection and Lemierre Syndrome

A 21-year-old man presented to an outside hospital with 10 days of fever, fatigue, and malaise. On exam, temperature was 106F, blood pressure 85/50 mm Hg, and heart rate 121 bpm. He was cold and clammy, with elevated jugular venous pressure, normal heart sounds, clear lungs, and cool extremities without edema. Laboratory results were notable for elevated white blood cell count (predominantly neutrophils), serum triglycerides, ferritin, C-reactive protein, coagulation parameters, and positive Monospot test. Following blood cultures, he was initiated on broad spectrum antibiotics, fluid resuscitated, and started on norepinephrine, epinephrine, and phenylepehrine. Shortly after transfer to our institution, although asymptomatic, an electrocardiogram demonstrated diffuse 5 mm ST-elevations with elevated cardiac biomarkers. A transthoracic echocardiogram demonstrated biventricular contractile dysfunction with ejection fraction 20% and apical akinesis. The patient was diagnosed with mixed cardiogenic and distributive shock. Cardiogenic shock was attributed to myocarditis with possible vasospasm or cytokine-induced myocardial suppression. Coronary angiogram was deferred given low suspicion for thrombotic acute coronary syndrome. Cardiac MRI showed subepicardial early and late gadolinium enhancement consistent with myocarditis, but negative viral serologies. Distributive shock was thought to be due to sepsis or hemophagocytic lymphohistiocytosis (HLH). The patient received empiric dexamethasone for HLH; and the diagnosis was confirmed on bone marrow biopsy. Blood cultures grew Fusobacterium necrophorum and neck imaging revealed thrombosis of the left internal jugular vein. Lemierre syndrome, thought to be bacterial invasion in the setting of tonsillitis was diagnosed. He was treated with antibiotics and dexamethasone with rapid clinical improvement and recovery of biventricular function. We suspect EBV infection lead to Lemierre syndrome and HLH with secondary myocardial suppression from the resultant cytokine storm. This case describes the first case of HLH-related myocarditis and highlights clinical decision-making surrounding the workup and management of mixed etiologies of shock with suspected myocarditis.

Internal Jugular Vein Thrombosis Following Different Types of Neck Dissection.

Introduction:During functional neck dissection, the surgeon tries to preserve the internal jugular vein (IJV); however, the incidence of its narrowing or obstruction following modified radical neck dissection (MRND) or selective neck dissection (SND) varies between 0% and 29.6%. The most distressing complication of IJV thrombosis (IJVT) is pulmonary embolism. This study aimed to evaluate the incidence of IJVT following selective or modified radical neck dissection. Materials and Methods:In this study, 109 neck dissections were performed with the preservation of the IJV on 89 patients from March 2011 to December 2012 in the Cancer Institute of Imam Khomeini Hospital Complex, Tehran, Iran. Ultrasound evaluation of the IJV was performed in the early postoperative period and three months after the surgery.Results:The study population consisted of 62 male and 27 female patients with a mean age of 57+17.57 years. Ultrasound evaluation of the IJV among the participants (109 veins) indicated thrombosis in nine veins (8.25%) in the early postoperative period, four of which remained thrombotic and without flow three months after the surgery. Moreover, 96.33% of the IJVs were patent with a normal blood flow three months after the neck dissection. Among the evaluated IJVs, the only factor that showed a significant association with IJVT was the incidence of postoperative complications, including hematoma and seroma (P=0.01). Conclusion:It seems that the most important factor for the prevention of the IJVT is a meticulous surgery and surgical complication avoidance during neck dissection.

Lemierre’s Syndrome: Is It So Rare?

The Lemierre syndrome, described in 1936 [1] is characterized by pharyngitis and peritonsilite complicated by septic internal jugular vein thrombosis and metastatic infections...

PANCOAST SYNDROME DUE TO A HIGH GRADE ANAPLASTIC TUMOR

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pancoast tumor is an uncommon type of lung cancer that arises from within the superior sulcus, with most clinical manifestations occurring due to mass effect. Pancoast syndrome describes symptoms that accompany such tumors. Symptoms include shoulder and arm musculoskeletal pain, Horner’s syndrome, and neurological complications of the upper extremities. Non-small cell lung cancers (NSCLC), most commonly adenocarcinoma is a predominant cause of Pancoast syndrome (1). CASE PRESENTATION: A 39-year-old male with a medical history of left-sided pneumothorax secondary to a stab wound and chronic cigar use presented to the hospital complaining of a right neck mass and right arm pain. Physical exam was notable for right supraclavicular lymphadenopathy. Initial labs were remarkable for leukocytosis of 13,200 cells/m3, hemoglobin 11 g/dl, lactate dehydrogenase 1590 IU/L, and ESR 92 mm/h. Neck CT with contrast showed a right side supraclavicular mass with right internal jugular vein thrombosis. Heparin infusion was initiated. Chest CT with contrast showed diffuse emphysematous changes, and a large bulky mass involving the medial right upper lobe and anterior mediastinum, with a mass-effect upon the brachiocephalic vein and superior vena cava consistent with Pancoast syndrome (image 1). Alpha 1 antitrypsin levels were normal. Ultrasound-guided biopsy of the right supraclavicular mass demonstrated a poorly differentiated malignant neoplasm composed of anaplastic cell sheets with extensive areas of necrosis. Immunohistochemical analysis was positive for CD34 and Vimentin (image 2). CT abdomen and pelvis showed multiple retroperitoneal nodal metastases and a right upper quadrant mass abutting the liver and posterior diaphragm. His tumor was inoperable, and palliative chemotherapy was elected. DISCUSSION: Most Pancoast tumors are caused by NSCLC(1), however, other malignancies can be responsible as well. In our patient, this occurred due to a poorly differentiated tumor with immunohistochemistry suggesting a possible mesenchymal origin. Surgery was contraindicated due to extensive local progression and distant metastases. In such patients, Site-specific chemotherapy can be selected based upon molecular testing and identification of the primary site (2). CONCLUSIONS: This case is notable for its rarity due to a poorly differentiated tumor of unknown primary site invaded the lung parenchyma and adjacent structures resulting in Pancoast’s syndrome. In such Cancer of Unknown Primary Site (CUP), empiric chemotherapy is the best treatment option available until further advancements in molecular targeted therapies are achieved (2). Reference #1: Marulli G, Battistella L, Mammana M, Calabrese F, Rea F.Superior sulcus tumors (Pancoast tumors). Ann Transl Med. 2016;4(12):239. doi:10.21037/atm.2016.06.16. Reference #2: Greco FA, Lennington WJ, Spigel DR, Hainsworth JD. Poorly differentiated neoplasms of unknown primary site: diagnostic usefulness of a molecular cancer classifier assay. Mol Diagn Ther 2015; 19:91. DISCLOSURES: No relevant relationships by christian ALMANZAR ZORRILLA, source=Web Response No relevant relationships by Omar Ansari, source=Web Response No relevant relationships by Mauricio Gomez, source=Web Response No relevant relationships by Seth Maxwell, source=Web Response No relevant relationships by Kishankumar Patel, source=Web Response No relevant relationships by Luis Silva, source=Web Response

MONOCLONAL ANTIBODY GONE ROGUE: ALEMTUZUMAB CAUSING ANTI-GLOMERULAR BASEMENT MEMBRANE DISEASE

SESSION TITLE: Medical Student/Resident Diffuse Lung Disease SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Anti-Glomerular basement membrane disease (anti-GBM), is a rare autoimmune process that can cause irreversible renal or lung injury. Here we discuss a case of Alemtuzumab induced anti-GBM. CASE PRESENTATION: A 46 year-old caucasian female with history of Multiple Sclerosis presented with flu-like symptoms, dizziness, nausea and vomiting ongoing for two weeks. Her physical exam was significant for dry mucous membranes and tachycardia. Her labs were significant for a BUN of 48 mg/dL and a creatinine of 6.8 mg/dL without any history of prior kidney disease. Renal biopsy revealed more than 90% glomerular involvement with necrotizing and crescentic proliferation, as well as positive linear staining along the glomerular basement membranes for IgG, Kappa, Lambda and C3. Anti-glomerular basement membrane antibodies were 189 units; thereby, Anti-GBM disease was diagnosed. Patient reported being on Alemtuzumab eight months prior to presentation. She was started on plasmapheresis, high dose prednisone and cyclophosphamide but therapy was stopped early due to nightly agitation and confusion likely related to sundowning, but the patient's family attributed it to the new therapy. Patient was discharged to inpatient rehab where she developed a right internal jugular vein thrombosis and was started on rivaroxaban. She later developed hemoptysis and had to be readmitted. Computed tomography scan of her lungs showed bi-apical and basilar dense airspace opacities with air bronchograms suggesting hemorrhagic infiltrates, findings were most consistent with diffuse alveolar hemorrhage. [Images A-C] Anti-GBM antibodies were elevated at 217 units. Patient was then restarted on plasmapheresis, steroids and cyclophosphamide and was able to complete therapy with slow but definite improvement. DISCUSSION: Alemtuzumab is a humanized monoclonal antibody that binds to CD52 (a cell-surface antigen present on T and B cells) and can be associated with anti-GBM disease that may present up to 40 months after the last dose.[1] Our case illustrates this lingering side effect and highlights the importance of taking a thorough history including previous and current medications. Our case shows the second reported case of Alemtuzumab induced anti-GBM with both renal and lung involvement [2] and the seventh case with renal involvement.[3-6] Our case is unique in the timing and course of development of kidney and lung injury, with about a month in between, while the first reported case showed a more rapid succession of kidney and lung injury. CONCLUSIONS: Alemtuzumab can be associated with autoimmune syndromes but clear screening tools and monitoring is not currently available. Further investigation is needed to identify a possible role for antibody monitoring in patients on Alemtuzumab. Reference #1: [1] Devonshire, V et al. Monitoring and management of autoimmunity in multiple sclerosis patients treated with alemtuzumab: practical recommendations. J Neurol 2018. Reference #2: [2] Lapointe, E., Moghaddam, B., Barclay, K., Traboulsee, A., & Neufeld, P. (2018). Goodpasture’s Syndrome Following Alemtuzumab Therapy in Multiple Sclerosis. Canadian Journal of Neurological Sciences / Journal Canadien Des Sciences Neurologiques, 45(6), 712-714. Reference #3: [3] Coles, AJ, Cox, A, Le Page, E, et al. The window of therapeutic opportunity in multiple sclerosis: evidence from monoclonal antibody therapy. J Neurol. 2006;253(1):98-108 [4] Meyer, D, Coles, A, Oyuela, P, et al. Case report of anti-glomerular basement membrane disease following alemtuzumab treatment of relapsing-remitting multiple sclerosis. Mult Scler Relat Disord. 2013;2(1):60-63. [5] Phelps, R. Autoimmune events: nephropathies. Scientific exchange forum 2013. [6] Singer, BA, Alroughani, R, Brassat, D, et al. Durable improvements in clinical outcomes with alemtuzumab in patients with active RRMS in the absence of continuous treatment: 7-year follow-up of CARE-MS II patients (TOPAZ study). Poster 736. 7th joint ACTRIMS-ECTRIMS meeting, Paris. 2017. DISCLOSURES: No relevant relationships by Youssef Abouleish, source=Web Response No relevant relationships by Paul Marik, source=Web Response

IF SORE THROAT WENT ROGUE: A CASE OF LEMIERRE'S SYNDROME

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 (LS) is a rare, but severe infectious illness caused by anaerobic bacteria usually Fusobacterium necrophorum. It is characterized by an initial oropharyngeal infection complicated by thrombophlebitis of the internal jugular vein (IJV) and septic embolization to other organs, commonly to the lung. Diagnosis requires a combination of clinical, radiological, and microbiological findings. CASE PRESENTATION: An 18-year-old man with sickle cell trait presented to the emergency department with fever and conjunctival icterus for 2 days. He had a sore throat 10 days ago, which was improving with ibuprofen. He subsequently developed nausea and vomiting followed by intermittent fever and icterus. He denied chest pain, dyspnea or body aches. He was febrile (103°F) and tachycardic (133 bmp). He had marked conjunctival icterus bilaterally and erythematous nasopharynx. Labs revealed mild anemia, leukocytosis (21,600 cells/mm3), acute kidney injury (creatinine of 2.4mg dL). His direct bilirubin was 16.5mg/dL, and indirect bilirubin was 3.2mg/dL. Serum LDH was 576 U/L, lactic acid was 2.8 mmol/L, d-dimer was 4.7mg/L. Hepatitis panel was negative. His chest X-ray showed multiple bilateral pulmonary nodules and CT chest demonstrated central cavitation of the nodules. The patient was started on broad-spectrum antibiotics for sepsis from possible pharyngitis. There was high suspicion for Lemierre's syndrome, but the CT neck was negative for thrombosis of IJV. Blood cultures grew Fusobacterium necrophorum and a diagnosis of LS was made. With anticoagulation and meropenem, based on susceptibilities, the patient improved. Further imaging studies revealed bilateral brachial vein thrombosis. He completed 4 weeks of antibiotics and 90 days of apixaban. DISCUSSION: Lemierre’s syndrome is a rare condition with an incidence of 0.5 to 1 per million, but has been steadily increasing. Delay in diagnosis and treatment may result in high mortality risk (5-18%). Patients usually present with resolving sore throat followed by severe sepsis. A diagnostic suspicion of LS with the clinical presentation is important because sometimes imaging and microbiological studies may not be helpful. This case was atypical due to the lack of IJV thrombosis. Culture data and a high index of suspicion led us to pursue additional imaging, revealing bilateral brachial vein thrombosis. Coverage with appropriate antibiotics and initiation of early anticoagulation is critical in the management of LS, since septic embolism, especially to the lung, is common. Fusobacterium necrophorum is usually susceptible to piperacillin-tazobactam, ampicillin-sulbactam, and metronidazole, but escalation to a broad spectrum carbapenem, like meropenem, should be considered if the patient is not improving. CONCLUSIONS: With the increasing incidence of LS, physicians need to be aware of its presentation, diagnosis, and management. Reference #1: Allen BW, Bentley TP. Lemierre Syndrome. [Updated 2019 May 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. https://www.ncbi.nlm.nih.gov/books/NBK499846/ DISCLOSURES: No relevant relationships by Mouna Gunda, source=Web Response No relevant relationships by Jewell Halanych, source=Web Response No relevant relationships by Prudhvi Regula, source=Web Response No relevant relationships by Julio Santana, source=Web Response

S2082 Importance of Coronavirus Disease 2019 Screening Before Endoscopic Procedures

INTRODUCTION: Asymptomatic coronavirus disease 2019 (COVID-19) is estimated to be between 15 to 40% of all cases. This needs to be distinguished from pre-symptomatic disease as patients are asymptomatic for a while, but eventually have symptoms. Since COVID-19 patients are contagious while asymptomatic, healthcare providers are at high risk of exposure. Although mass testing may prevent healthcare worker exposure, mass testing may not be possible due to insufficient healthcare resources. To illuminate the importance of COVID-19 screening, we present a 66 year-old asymptomatic male with a COVID-19 positive screen before an esophagogastroduodenoscopy (EGD). CASE DESCRIPTION/METHODS: A 66 year-old African American non-Hispanic male with a past medical history of ischemic stroke, hypertension, and hyperlipidemia, presented to the emergency department with bright red blood per rectum and melenic stool. He denied any fever, chills, night sweats, cough, dyspnea, abdominal pain, diarrhea, nausea, or vomiting. His bleeding began one week after starting apixaban for a left internal jugular vein thrombosis. Initial laboratory was significant for a microcytic anemia (11.2 g/dL). Therefore, he was admitted for further evaluation of gastrointestinal bleed. Gastroenterology was consulted and recommended proceeding with an EGD. However, recent hospital guidelines warranted COVID-19 screening in all patients undergoing a procedure. Although the patient had asymptomatic respiratory symptoms, he tested positive for COVID-19. Therefore, endoscopy was cancelled. Once serial hemoglobin was stable, he was discharged after two days of hospitalization. DISCUSSION: Healthcare workers are at high risk of COVID-19 infection. In an observational study enrolling 1,099 Chinese patients infected with COVID-19, 3.5% were healthcare workers. Gastroenterologists are at high risk of infection as some procedures create viral aerosolization. However, pre-endoscopic and nationwide screening could decrease infection rate. South Korea successfully contained COVID-19 spread through mass testing. Although such solution could be implemented in the United States, insufficient healthcare utilization of resources including limited tests and reagent supplies are potential hurdles. We present the importance of COVID-19 screening before endoscopy. Although the long-term benefits of pre-endoscopic COVID-19 screening is not well known, pre-endoscopic screening may be an effective way to limit healthcare worker exposure.

Neurovascular Complications After Neck Dissection: a Prospective Analysis at a Tertiary Care Centre in South India

Owing to high incidence of oral cancers in India, neck dissection is the most commonly performed procedure in any head and neck oncology setup. This surgery is particularly prone to various neurovascular complications due to intricate anatomy of neck, but the exact incidence has been studied less especially in Indian subcontinent. A prospective observational study was done on 105 patients of oral cancer who underwent neck dissection at Regional Cancer Centre, Trivandrum, and various short-term and long-term neurovascular complications were recorded. There was high temporary praxia of marginal mandibular and greater auricular nerve of 32.5% and 36.1%, respectively, immediate post-operative period which reduced significantly during 6months. Eight patients had long-term shoulder abduction difficulty. There were isolated cases of IJV thrombosis and phrenic nerve paralysis. Despite our best intentions, complications arise due to complex anatomy of the neck, but if surgeon remains cognisant of the potential complications, their impact on patients' health, pocket and hospital resources can be minimized.

Clinical Classification and Collateral Circulation in Chronic Cerebrospinal Venous Insufficiency.

Background: As an indispensable part of the cerebral venous system, the extracranial cerebrospinal venous system is not fully recognized. This study aimed to analyze the clinical classification and imaging characteristics of chronic cerebrospinal venous insufficiency (CCSVI) quantitatively.Methods: A total of 128 patients, who were diagnosed as CCSVI by jugular ultrasound and contrast-enhanced magnetic resonance venography (CE-MRV), were enrolled from May 2018 through May 2019. For the patients with possible extraluminal compression, computed tomography venography (CTV) was applied to estimate the degree of internal jugular venous stenosis (IJVS) and rank the vertebral venous collateral circulation.Results: The causes of extraluminal compression induced IJVS included osseous compression (78.95%), carotid artery (24.21%), sternocleidomastoid muscle (5.79%), swollen lymph node (1.05%), and unknown reasons (5.26%). The subtypes of non-compression CCSVI included the high jugular bulb (77.27%), fenestration of the internal jugular vein (IJV) (7.27%), internal jugular phlebectasia (2.73%), tortuous IJV (0.91%), IJV thrombosis (14.55%), and elongated venous valves with/without erythrocyte aggregation (13.64%). For extraluminal compression induced IJVS, the ratio of severe vertebral venous expansion was higher in the severe IJVS group than that in the mild IJVS group (p < 0.001). The IJVS degree was higher in the severe vertebral venous expansion group than in the mild vertebral venous expansion group (p < 0.001).Conclusions: A multimodal diagnostic system is necessary to improve the diagnostic accuracy of CCSVI. The vertebral venous system is an important collateral circulation for CCSVI, which may be a promising indicator for evaluating IJVS degree.

A Novel Account of the 'Forgotten Disease'

Introduction&#x0D; Septic thrombophlebitis of Internal Jugular Vein (IJV) secondary to head neck infection, demonstrated by Lemierre in 1936, is a rare although known entity.&#x0D; Case Report&#x0D; 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. &#x0D; Discussion&#x0D; 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.

Unusual Dialysis Catheter Location in a Transplant Patient.

A 56-year-old woman, the recipient of a kidney transplant 8 years ago, was admitted to the nephrology intensive care unit with septic shock secondary to disseminated shingles after immunosuppressive therapy for acute cellular rejection. The patient developed AKI requiring RRT. Due to history of right internal jugular vein thrombosis related to previous vascular access, the left internal jugular vein was catheterized with a nontunneled double lumen hemodialysis catheter (12 French, 20 cm) without any complications. Routine postprocedure chest radiograph (Figure 1A) showed that the catheter was descending straight into the left border of the mediastinum. A transthoracic echocardiogram then showed enlarged coronary sinus with normal size cardiac chambers and no septal defects. Figure 1. Imaging studies exposing the persistent left superior vena cava. (A) Chest radiograph showing dialysis catheter descending straight to the left border of the mediastinum. (B) Anteroposterior three-dimensional computed tomography angiography (CTA) reconstruction revealing …

Profile of natural anticoagulant, coagulant factor and anti-phospholipid antibody in critically ill COVID-19 patients.

The outbreak of novel coronavirus disease 2019 (COVID-19) has now become a global pandemic. Coagulopathy has been reported widely in critically ill COVID-19 patients and was related to high mortality. However, the comprehensive coagulation profiles have not been examined and the underlying mechanism of the coagulopathy in COVID-19 patients is unclear. To study the coagulation profiles of routine hemostasis tests, natural anticoagulants, coagulant factors and antiphospholipid antibodies in critically ill COVID-19 patients. This single-center and cross-section study included 19 patients with COVID-19, who were admitted to intensive care unit (ICU) at Tongji hospital in Wuhan, China, from Feb 23 to Mar 3, 2020. Demographic data, laboratory parameters, treatments and clinical outcomes of the patients were collected and analyzed. The final date of follow-up was Mar 31, 2020. In this study, 12 thrombotic events occurred in 9 patients, including 4 cerebral infarctions, 7 acro-ischemia and 1 internal jugular vein thrombosis. The common abnormalities of routine coagulation tests included evelated D-Dimer level (100%), prolonged prothrombin time (73.7%) and hyperfibrinogenemia (73.7%). The median activities of natural anticoagulants including protein C, protein S and antithrombin were all below the normal range. Factor VIII activities were significantly above normal range (median value 307%, IQR 198–441) in all patients. Factor V and factor VII activities were significantly lower in near-terminal stage patients. Anti-phospholipid antibodies were present in 10 patients. Strikingly, 4 cerebral infarction events were in patients had anti-phospholipid antibodies of multiple isotypes. Sustained hypercoagulable status and thrombotic events were common in critically ill patients with COVID-19. The low activities of natural anticoagulants, elevated factor VIII level and the presence of antiphospholipid antibodies, together, may contribute to the etiopathology of coagulopathy in COVID-19 patients.

Cutaneous Complications Secondary to Haemostasis Abnormalities in COVID-19 Infection.

We describe the case of a patient hospitalized for acute decompensated heart failure in a standard medical ward. During hospitalization, he was diagnosed with COVID-19 and transferred to a special unit. The clinical course was marked by worsening of the respiratory disease, the development of right parotiditis and thrombosis of the left internal jugular vein. Therapeutic anticoagulation was initiated and 2 days later, the minimal dermatoporosis lesions previously present in the upper extremities evolved to haemorrhagic bullae with intra-bullae blood clots and dissecting haematomas. Surgical management of the dissecting haematomas was difficult in the context of haemostasis abnormalities. The patient died 29 days after hospital admission.LEARNING POINTSSingle room accommodation should be preferred to double room accommodation in standard wards during the COVID-19 pandemic.Anticoagulation therapy and the presence of lupus anticoagulant may induce cutaneous complications during COVID-19 infection.The discontinuation of anticoagulation therapy did not help improve the management of cutaneous lesions.

Suppurative cervical lymphadenitis in adult: An analysis of predictors for surgical drainage

ObjectiveLymphadenitis can be treated successfully by empirical antibiotic therapy. However, inflamed lymph nodes can progress into an abscess with local and/or systemic reaction, which requires more complex treatment strategies. The study aim to analyze possible predictors for abscess formation within inflamed nodes that require surgical drainage. Materials and MethodsWe retrospectively enrolled 241 patients with acute or sub-acute cervical lymphadenitis. Demographic including, lymph node characteristics, management, and final diagnosis were recorded. Predictors for abscess formation within the lymph node that required surgical drainage were evaluated using univariate and multivariate analysis. Patient and lymph node characteristics that differentiated suppurative cervical lymphadenitis (SCL) from other lymphadenitis were also analyzed. ResultsThere were 41 cases of SCL, 173 cases of uncomplicated cervical lymphadenitis, and 27 cases of tuberculous cervical lymphadenitis (TBLN). Abscess was surgically drained in 39 patients, while 2 patients received a needle aspiration. In 9 patients, SCL complications included cellulitis of the neck soft tissue, supraglottic swelling, internal jugular vein thrombosis, and sepsis. Two patients were diagnosed with melioidosis and actinomycosis after drainage. Multivariate analysis showed that an immunocompromised host, male sex, and receiving prior inadequate treatment were predictors for surgical drainage. TBLN patients had similar manifestations as SCL patients. However, affected nodes in SCL patients were singular, painful, and showed fluctuation. ConclusionsFollowing SCL diagnosis, abscess drainage and appropriate antibiotic treatment should be considered. Aspiration or surgical drainage can be effective in certain patients. Pathogen isolation and tissue biopsy should be performed to ensure accurate diagnosis and antibiotic selection. In addition, TBLN and melioidosis should be considered, especially in endemic areas.

Resection for Internal Jugular Vein Thrombosis and Cervical Lymph Nodes' Involvement from Gastric Cancer.

Thrombosis internal jugular vein (IJV) with cervical adenopathy, as first manifestation of gastric cancer is rare. We aimed to compare resection of the cervical mass followed by gastrectomy with gastrectomy alone. Nine patients presenting thrombosis of the IJV for gastric carcinoma were divided into two groups. Patients in group A (n=3) underwent anticoagulation treatment, gastrectomy and adjuvant treatment. Patients in group B (n=6) underwent resection of the cervical mass and internal jugular vein (radical neck dissection), and then gastrectomy and adjuvant treatment. Median survival was 15.3 months in group A (range=11-19 months) and 31.2 months in group B (range=7-44 months) (p=0.11). Late cervical recurrence/complications occurred in 2 patients in group A and none in group B (p=0.02). Resection of thrombosed IJV and satellite lymph nodes, due to a primary gastric cancer may contribute to diagnosis of the disease, limit pulmonary embolic complications and improve quality of life.