Emphysematous thrombophlebitis caused by a misplaced central venous catheter: A case report

BACKGROUND Central venous catheters(CVCs)often cause life-threatening complications,especially CVC-related bloodstream infection(CVC-BSI)and catheter-related thrombosis(CRT).Here,we report an unusual case of misplaced CVC-induced emphysematous thrombophlebitis,a rare but potentially lethal form of CRT and CVC-BSI characterized by both thrombosis and gas formation.CASE SUMMARY A 48-year-old male presented to the emergency room of a local hospital with sudden-onset headache and coma for 4 h.Computed tomography(CT)revealed right basal ganglia hemorrhage,so emergency decompressive craniotomy was performed and a CVC was inserted through the right subclavian vein for fluid resuscitation during anesthesia.Two days later,the patient was transferred to the intensive care unit of our hospital for further critical care.On day 9 after CVC insertion,the patient suddenly developed fever and hypotension.Point-of-care ultrasound(POCUS)demonstrated thrombosis and dilatation of the right internal jugular vein(IJV)filled with thrombosis.Ultrasonography also revealed that the CVC tip had been misplaced into the IJV and was surrounded by gas bubbles,which manifested as hyperechoic lines with dirty shadowing and comet-tail artifacts.Further CT scan confirmed air bubbles surrounding the CVC in the right neck.The final diagnosis was septic emphysematous thrombophlebitis induced by a misplaced CVC and ensuing septic shock.The responsible CVC was removed immediately.The patient received fluid resuscitation,intravenous noradrenaline,and a 10-d ultra-broad spectrum antibiotic treatment to combat septic shock.Both CVC and peripheral venous blood cultures yielded methicillin-resistant Staphylococcus cohnii.The patient was gradually weaned off vasopressors and the symptoms of redness and swelling in the right neck subsided within 7 d.CONCLUSION Emphysematous thrombophlebitis is a fulminant and life-threatening CVC-BSI associated with thrombosis and gas formation in the vein.A misplaced CVC may facilitate the development of emphysematous thrombophlebitis.POCUS can easily identify the artifacts produced by gas and thrombosis,facilitating rapid diagnosis at the bedside.

Pylephlebitis-induced acute liver failure: A case report and review of literature

BACKGROUND Pylephlebitis is an extremely rare form of septic thrombophlebitis involving the portal vein,carrying high rates of morbidity and mortality.CASE SUMMARY We present a case of a 42-year-old male with no past medical history who presented with acute onset of abdominal pain and altered mental status with laboratory tests demonstrating new-onset acute liver failure.Pylephlebitis was determined to be the underlying etiology due to subsequent workup revealing polymicrobial gram-negative anaerobic bacteremia and complete thrombosis of the main and left portal veins.To our knowledge,this is the first documented case of acute liver failure as a potential life-threatening complication of pylephlebitis.CONCLUSION Our case highlights the importance of considering pylephlebitis in the broad differential for abdominal pain,especially if there are co-existing risk factors for hypercoagulability.We also demonstrate that fulminant hepatic failure in these patients can potentially be reversible with the immediate initiation of antibiotics and anticoagulation.