Phlebitis migrans

Published on 02/04/2015 by admin

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163 Phlebitis migrans

Instruction

Look at this patient’s leg: he has had similar such lesions at different sites at intervals.

Diagnosis

This patient has migratory phlebitis (lesion) and I would like to investigate for an underlying pancreatic or gastric malignancy (aetiology).

Advanced-level questions

In which other condition is superficial phlebitis a prominent sign?

Thromboangiitis obliterans (N Engl J Med 2000;343:864).

Is superficial thrombophlebitis associated with deep vein thrombosis?

It may be associated with occult deep vein thrombosis in about 20% of cases, although pulmonary emboli are rare.

Is phlebitis more frequently associated with plastic venous catheters or with steel intravenous needles?

It is more likely to be associated with plastic catheters, but this may be caused by the catheter remaining in the vein for longer periods (Fig. 163.1).

Fig. 163.1 Venous flare reaction overlying access vein of the forearm.

(With permission from Abeloff et al. 2008.)

How is superficial phlebitis treated?

• Local heat, elevation of the leg and NSAIDs

• When very extensive or in proximity to the saphenofemoral junction, ligation and division of the saphenous vein at the saphenofemoral junction (as pulmonary embolism may result if the phlebitis of the saphenous vein extends into the deep vein)

• Septic thrombophlebitis, which is usually caused by Staphylococcus aureus, requires excision of the involved vein up to its junction with an uninvolved vein in order to control infection.

What other dermatoses complicate pancreatic disease?

• Panniculitis

• ‘Bronze’ pigmentation of haemochromatosis

• ‘Necrolytic migratory erythema’ of glucagonoma syndrome

• Cutaenous haemorrhage of acute pancreatitis: ‘bruising’ of the left flank (Grey Turner’s sign) or umbilicus (Cullen’s sign) (see Fig. IV.1).

What is relationship between venous thromboembolism and cancer?

Cancer risk is increased in patients with venous thromboembolism. Several reports have shown an increase over rates in the general population during the first 1 or 2 years after admission for venous thromboembolism: a four-fold increase in the first year, particularly for cancers of the brain, liver, pancreas and ovary, Hodgkins’s disease and polycythaemia vera (Lancet 1998;351:1077–80); an advanced stage and poor prognosis for cancer diagnosed at the same time or in the following year (N Engl J Med 2000;343:1846–50). The risk seems to be lower among patients treated with oral anticoagulants for 6 months than those treated for 6 weeks (N Engl J Med 2000;342:1953–8).

A long-term risk has also been identified: a 30% increased overall incidence of malignancy over a 10-year period (Lancet 1998;351:1077–80).

Armand Trousseau (1801–1867), physician at the Hôtel-Dieu in Paris, noted the sign as his death warrant, confirming his suspicion of an underlying malignancy in 1865. (Trousseau A. Phlegmasia albia dolens. In Lectures on clinical medicine, delivered at the Hôtel-Dieu, Paris, London: New Wydenham Society, 1872, pp. 281–295).

G Grey Turner (1877–1951), Professor of Surgery, Hammersmith Hospital, London.

TS Cullen (1868–1953), Canadian born, Professor of Gynaecology, Johns Hopkins Hospital, Baltimore, USA.

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