[Bacterial Meningitis and Suppurative Thrombophlebitis after Trigger Point Injections: A Case Report].

A 73-year-old woman with untreated diabetes mellitus visited our emergency department with a 4-day history of progressive headache, fever, and chills. She received trigger point injections (TPI) into the right sternocleidomastoid for exercise-induced ipsilateral shoulder pain, 13 days before admission and into the right trapezius, 6 days before admission. Cerebrospinal fluid (CSF) evaluation revealed pleocytosis with a predominance of neutrophils, as well as elevated protein and reduced glucose levels. Magnetic resonance imaging of the cervical spine revealed inflammatory changes of the right-sided posterior cervical muscles and the right vertebral arch of the C5-C6 vertebrae without contrast enhancement of the right posterior cervical veins. She was diagnosed with bacterial meningitis and suppurative thrombophlebitis, and empiric broad-spectrum antibiotic therapy was administered intravenously. The initial blood culture yielded Streptococcus intermedius; however, CSF culture showed no growth. She recovered completely after a 4-week course of intravenously administered ampicillin and was discharged with oral clindamycin to complete a total 6-week antibiotic course. TPI are widely used as a safe therapeutic strategy associated with few complications, and serious infections are rare. However, clinicians must remain mindful of the possibility of these complications in immunocompromised patients, such as those with diabetes mellitus who undergo TPI. (Received September 18, 2020; Accepted December 21, 2020; Published June 1, 2021).

Trombosis de la vena espermática derecha. Revisión de la literatura a propósito de un caso / Right spermatic vein thrombosis. Revision of literature regarding a specific case

La tromboflebitis aguda de la vena espermática es una dolencia de muy baja frecuencia, con afectación mayoritaria del lado izquierdo, y de etiología desconocida en la mayoría de las ocasiones. Suele ser un hallazgo inesperado en el diagnóstico diferencial del dolor testicular agudo. Se trata de un varón de 29 años con un consumo abusivo de cocaína que acude con dolor testicular agudo. Se confirma la afectación de la vena espermática derecha mediante ecografía-doppler. Se optó por manejo conservador con anticoagulación y antiinflamatorios. La eco-doppler es la técnica con mayor especificidad y sensibilidad para diagnosticarlo, mientras que la TC puede completar su diagnóstico etiológico. El tratamiento de elección es conservador basado en la anticoagulación del paciente. Es imperativo un estudio hematológico en búsqueda de alteraciones de la coagulación (AU)

Acute thrombophlebitis of spermatic vein is an unusual pathology involving, in most of the cases, the left side, and whose etiology remains uncertain. Most of them are found during a a differential diagnosis in acute testicular pain. We introduce the case of a 29 years old male with abusive cocaine consumption, admitted to hospital due to severe testicular pain. Doppler-ultrasound examination was undertaken, showing right spermatic vein flux alteration. Conservative management was decided and anticoagulant and non-esteroidal anti-inflammatory drugs were started. Eco-doppler is the most specific and sensible technique for diagnosis of these cases, while TC can always confirm etiologic diagnosis. Treatment was initially conservative based on anticoagulation. Hematological study is necessary in order to determine coagulation alterations (AU)

The arteriovenous impulse system in total hip arthroplasty.

BACKGROUND: Despite the continuing high incidence of deep vein thrombosis after total hip arthroplasty, currently available mechanical thromboprophylactic systems are not sufficiently utilised in Germany. PATIENTS AND METHODS: Duplex-sonographic measurements of the maximum venous flow velocity (V. femoralis) in 10 healthy individuals performed with a leg orientation synonymous to that during total hip arthroplasty were compared to figures obtained during an out-stretched leg position. Additionally, duplex-sonography was conducted on 9 patients intra-operatively during total hip replacement to complete the study. All investigations were executed both with and without application of the A-V Impulse System (AVIS), a mechanical thromboprophylactic procedure. RESULTS: In contrast to the out-stretched leg position, a decreased venous peak flow velocity during surgery as well as in the operation-identical leg orientation was demonstrated in the absence of AVIS. However, by means of AVIS, a significant increase in the venous peak flow velocity (p < 0.01) was achieved for both situations. Additionally, an increased vessel diameter of the V. femoralis communis was observed in 75% of patients due to the leg orientation stipulated for hip replacement surgery. CONCLUSION: The data suggest that the A-V Impulse System can effectively accelerate the venous reflux-flow during operations involving hip replacements and thus provide an early preventative therapy for deep vein thrombosis after a surgical procedure.

Effect of preoperative donation of autologous blood on deep-vein thrombosis following total joint arthroplasty of the hip or knee.

The effect of preoperative donation of autologous blood on postoperative deep-vein thrombosis was retrospectively studied in men who had been managed consecutively with elective total joint replacement of the hip or knee because of osteoarthrosis. The patients had, on the average, two of nine considered risk factors for deep-vein thrombosis. Two hundred and thirty-seven patients were evaluated postoperatively with ascending venography, and they form the basis of this study. Fifty-four patients had venographic evidence of deep-vein thrombosis of the lower extremity, with most having asymptomatic clots distal to the knee. The prevalence of deep-vein thrombosis was nineteen (16 per cent) of 116 after total hip arthroplasty, compared with thirty-five (29 per cent) of 121 after total knee arthroplasty (chi square=4.6, p=0.03). Deep-vein thrombosis developed in twenty-eight (17 per cent) of the 161 patients who had donated blood preoperatively, compared with twenty-six (34 per cent) of the seventy-six patients who had not donated blood preoperatively (chi square=7.7, p=0.006). Through logistic regression analysis, the donation of autologous blood was shown to reduce significantly the development of postoperative deep-vein thrombosis for patients managed with total knee arthroplasty (p<0.01) but not for patients managed with total hip arthroplasty. Additional neural network analysis showed the donation of autologous blood to be the most important prognostic factor in predicting the absence of postoperative deep-vein thrombosis. In addition to diminishing the need for transfusion of homologous blood after total joint arthroplasty, preoperative donation of autologous blood appears to protect against postoperative deep-vein thrombosis after total knee arthroplasty.

[Alternative therapy of deep venous thrombosis in patients at hemorrhagic risk]. / Terapia alternativa della trombosi venosa profonda nel paziente a rischio emorragico.

The authors report on the pharmacological employment of defibrotide in the treatment of a case of deep vein thrombosis (DVT) of the left iliac-femoral veins in a patient with a high-risk of hemorrhage (haematuria from kidney neoplasm, rupture of basilar artery aneurysm, urethral bleeding from catheter trauma). Alternatively to the traditional thrombolytic and anticoagulants, not indicated here for their haemorrhagic risk potential, defibrotide promptly resolved the DVT without any major effect on blood coagulation parameters. Initially, 1 gr of defibrotide in 250 ml of glucose-1-phosphate solution was administered twice-daily for the first two days when improvement had been observed. An additional 5 days of therapy was continued under the same regimen, then 400 mg intravenously every 2 hours for 14 days, and 400 mg intramuscularly every 24 hours until the 30th day. The patient was dismissed from the hospital on therapy with indobufen 200 mg orally, and elastic support stocking. After 6 months the patient is well. An echo color Doppler evaluation showed a normal venous blood flow through the femoral, iliac and caval veins, and venous blood reflux in the iliac-femoral and femoral saphenous veins due to valvular insufficiency. Caval filters, although recognized by many institutions as a preferred method of protection against pulmonary thromboembolism especially in patients with a contraindication to anticoagulation therapy or recurrent pulmonary embolism, was not used in this case, since the patient was critically ill. From this case report and the review of the literature it seems that defibrotide may represent a valid alternative therapy in the treatment of DVT, especially in high risk haemorrhagic patients.

[Transcutaneous electric muscle stimulation--a "new" possibility for the prevention of thrombosis?]. / Die transkutane elektrische Muskelstimulation--eine "neue" Möglichkeit zur Thromboseprophylaxe?

Adhesive electrodes for transcutaneous electrical stimulation of the calf were applied on the skin of 11 patients with ruptures of the fibular ligaments (treated surgically or conservatively with cast) during the period of immobilisation (four weeks). Muscle stimulations were performed several times a day over a period of at least 15 minutes with a small rechargable muscle stimulation apparatus. Duplex sonography revealed that a significant rise of the venous flow velocity could be achieved with an 8.5-fold increase of the venous flow velocity as measured over the popliteal vein. Transcutaneous muscle stimulation might move to be a "new" efficient method for the prophylaxis of deep vein thrombosis.

Hereditary protein S deficiency in a large New Jersey kindred.

PURPOSE: Protein S is a vitamin K-dependent anticoagulant protein that serves as a cofactor for activated protein C. Deficiency of protein S has been associated with recurrent thrombotic events. To characterize better the risks of thrombosis in protein S deficiency, we studied 62 members in a large kindred. METHOD: All members were evaluated by a thorough clinical history. Plasma samples were assayed for total protein S antigen and protein S activity. Upper and lower extremity venous duplex examinations were performed in the majority of adult members. RESULT: Twenty-six (40%) of the 62 family members were classified as deficient on the basis of either low total protein S antigen levels or low protein S functional activity. Five members deficient in protein S had 16 venous thrombotic events. In all members the onset of thrombotic events occurred after 19 years of age, with a tendency for recurrence. Three lower extremity deep venous thromboses that had been occult previously were first diagnosed on surveillance duplex scanning. Only one member whose protein S level was not deficient had a single episode of superficial thrombophlebitis. CONCLUSION: Our findings in this large kindred confirm an autosomal-dominant inheritance pattern. Thrombotic events occurred after the age of 19 years in affected individuals and tended to be recurrent. The diagnosis of protein S deficiency is based on functional and immunologic plasma assays. In this study venous duplex scanning proved to be a useful diagnostic adjuvant.

Radionuclide venography of lower limbs by subcutaneous injection: a clinical evaluation.

SC-RNV, radionuclide venography by subcutaneous injection of Tc-99m pertechnetate at acupuncture points K-3, a new alternative of lower limb venography, was recently developed in our clinical laboratory. In some of the previous studies, we have proved its superiority to radionuclide venography by intravenous injection. The current investigation was conducted to understand the reliability of SC-RNV in the diagnosis of deep vein thrombosis (DVT). Fifty-seven cases with lower leg edema, from Nov., 1989 through Oct., 1990, received both SC-RNV and duplex US for causative evaluation. As a result of duplex US, 26 were considered normal (non-DVT), 19 were classified as unilateral DVT, and 12 as bilateral DVT. In nineteen cases (61%, 19/31) with DVT also a XCT and/or a CV (contrast venography) was taken, that showed compatible results. All of the non-DVT had a normal pattern of SC-RNV, all of the unilateral DVT had unilateral impairment of deep vein drainage in SC-RNV, and all of the bilateral DVT had impaired deep venous drainage bilaterally in SC-RNV. It is therefore concluded that SC-RNV is one of the best choices among available non-invasive lower-limb venographic methods.

[Regional hyperthermic fibrinolytic perfusion in postoperative deep venous thrombosis of the leg]. / Regionale hypertherme Fibrinolytika-Perfusion bei postoperativer tiefer Beinvenenthrombose.

Four days after an operation for fusion of lumbar and sacral vertebrae a 30-year-old man developed bilateral deep-vein thrombosis in the legs, extending on the left from the fibular group of veins to the popliteal vein. On the right all deep veins of the lower leg were occluded, including the confluence of the popliteal vein. As systemic fibrinolysis was contraindicated, surgical thrombectomy was undertaken. After incomplete removal of the thrombi, regional hyperthermic perfusion with streptokinase was performed using a heart-lung machine. After a compression bandage had been applied to the right leg above the veins the leg was perfused via the common femoral vein at 40 degrees C from the heart-lung machine, at a flow rate of 600-800 ml/min, for 60 min with a solution containing 1 million IU streptokinase. Measurement of various components in the perfusate indicated marked fibrinolysis (fibrinogen: not measurable; fibrinogen breakdown products: > 80 micrograms; streptokinase: 100 FU/ml after 30 min, 62 FU/ml after 60 min). At the same time there was no demonstrable fibrinolytic activity in the systemic circulation. Fibrinogen concentration fell from 340 mg/dl 30 min before the onset of perfusion to 245 mg/dl 90 min after it. After 60 min of perfusion the blood from the right leg was discarded and the leg flushed through with 1.5 l of an electrolyte solution and then filled up with previously obtained and stored patient's own blood concentrate. Subsequent phlebography and venous occlusion plethysmography demonstrated complete recanalization of the deep-vein system with normal venous valve function.

The use of indium-111 labeled platelet scanning for the detection of asymptomatic deep venous thrombosis in a high risk population.

Five hundred indium-111 labeled platelet imaging studies (387 donor and 113 autologous) were performed postoperatively in 473 patients who had undergone total hip replacement, total knee replacement, or internal fixation of a hip fracture to detect occult deep venous thrombosis. All patients had been anticoagulated prophylactically with aspirin, warfarin sodium (Coumadin), or dextran. Thirty-four possible cases of proximal deep venous thrombosis were identified in 28 asymptomatic patients. To verify the scan results, 31 venograms were performed in 25 patients (three refused). In 21 of 31 cases, totally occlusive thrombi were detected; in 5 cases, partially occlusive thrombi were detected; in 5 cases, no thrombus was seen. No patient who had a negative scan nor any patient who had a verified positive scan (and received appropriate heparin therapy) subsequently developed symptoms or signs of pulmonary embolism. One hundred forty-one indium study patients also underwent Doppler ultrasonography/impedance plethysmography (Doppler/IPG) as a comparative non-invasive technique. In 137 cases, the results of the indium study and Doppler/IPG studies were congruent. The indium study had no false negative results that were detected by Doppler/IPG. No patient had any clinically evident toxicity. These results suggest that indium-111 labeled platelet scanning is a safe, noninvasive means for identifying DVT in high risk patients.

Radionuclide venography of lower limbs by subcutaneous injection: comparison with venography by intravenous injection.

We have proved that subcutaneous injection (SC) of a small dose of Tc-99m pertechnetate (1 to 2 mCi: 37 to 74 MBq) at acupuncture points (K-3 and B-60) may offer an alternative method of radionuclide venography (RNV) of the lower limbs. In this study, we compared intravenous (IV) RNV and SC-RNV in 22 consecutive cases with typical signs and symptoms suggesting venous abnormality of the lower limb(s) from March to May 1988. They are 11 male and 11 female, aged 47.7 +/- 15.7 years. Among the 44 limbs of the 22 cases, 4 were normal, 12 (27.3%) were found to have varicose veins in the legs only, 18 (40.9%) had partial stenosis of the deep veins (14 poplito-tibial and 4 superficial femoral), and 13 (29.6%) had complete stenosis of the deep veins (4 poplitotibial, 1 superficial femoral and 8 ilio-femoral. SC-RNV showed almost the same results as IV-RNV in 21 (47.7%), superior to IV-RNV in 22 (50%) (including 4.6% failure of IV-RNV), and inferior to IV-RNV in 1 (2.3%). We conclude that SC-RNV is definitely an alternative method of lower-limb venography. Since it is in most cases superior to IV-RNV, we suggest that it can take the place of IV-RNV in routine work.

Imaging thrombi with radiolabelled fragment E1.

Fragment E1 is a fragment of human fibrin, produced by controlled plasmin digestion of cross-linked fibrin. It comprises the N-terminal regions of all six polypeptide chains of fibrin. It has been shown to contain a pair of dimeric binding sites which are complementary in binding to sites in the D domains of fibrin which are formed when fibrin polymerizes, so fragment E1 binds to fibrin dimers and polymers but not fibrin monomer or fibrinogen. Radioiodinated fragment E1 has been shown to localize in venous thrombi in a pig model. Thrombus/blood ratios of up to 100: 1 were obtained at 24 h post injection, in thrombi up to 5 days old at the time of tracer injection. In humans, deep-venous thrombi were visualized within 30 min of 123I-labelled fragment E1. Fragment E1 exhibits very rapid blood disappearance, which enhances its ability to produce high thrombus/blood ratios at early times. The thrombus uptake of labelled fragment E1 is not affected by heparin. Fragment E1 has been derivatized with metal chelating groups [diethylene-triaminepentaacetic acid (DTPA) and deferoxamine], to facilitate labelling with 111In and 67Ga. Although these labels appeared promising in animal models, they have not yet achieved success in man. Clinical trials are continuing with 123I-labelled fragment E1, which is felt to be a most promising radiopharmaceutical for thrombus localization.

[Nuclear medicine diagnosis in venous diseases of the extremities]. / Nuklearmedizinische Diagnostik bei Venenerkrankungen der Extremitäten.

The 125I fibrinogen test and radionuclide venography have so far been the two standard methods of thrombosis diagnosis via nuclear medicine. Both methods have been developed further as a result of scientific and technical advances in recent years. Direct visualisation of thrombi with the help of 111indium thrombocytes is becoming increasingly important. Direct visualisation of thrombi can be made still easier by antithrombocytic antibodies. In case of contrast medium intolerance, and in diagnosing pulmonary embolism, radionuclide venography can still be useful in combination with lung perfusion scintigraphy, even if nonionic x-ray contrast media are increasingly introduced. The diagnostic possibilities offered by contrast medium venography in respect of precise morphological vascular imaging and function diagnosis, are complementary in many problems of venous diagnostics.

Post-operative thromboembolism in neurosurgery. A study on the prophylactic effect of calf muscle stimulation plus dextran compared to low-dose heparin.

This study compares the safety and effectiveness of two methods for the prophylaxis of post-operative thromboembolism in neurosurgical patients: A: low-dose heparin (5,000 IU X 2 s.c.) started preoperatively and continued daily for one week post-operatively, and B: per-operative electrical calf muscle stimulation with groups of impulses plus post-operative dextran infusions every other day for one week. Neurosurgical patients aged 40 years or more with normal laboratory coagulation values and operated under general anaesthesia were included. The 125:I-fibrinogen uptake test (FUT) was used for screening and phlebography for verification of deep venous thrombosis (DVT). 122 patients entered the study and 104 completed the prophylactic protocol, 58 in group A and 46 in group B. The two groups were comparable according to pre-operative data and distribution of diagnoses. 89 patients completed screening for post-operative DVT. We found an overall incidence of 5/49 (10 percent) DVT in group A and 5/40 (13 percent) in group B, compared to a frequency of 32-50 percent for controls without prophylaxis reported in the literature, In spite of prophylaxis our patients with intracranial neoplasms and intracranial vascular disease showed a relatively higher incidence of DVT, 4/23 (17 percent) and 4/14 (29 percent) respectively, compared to patients with spinal diagnoses 2/25 (8 percent). In combination with cranial diagnoses paretic lower limbs meant an apparent risk factor, 4/7 (57 percent). However, paretic limbs appearing in cases with spinal disorders did not predetermine an unsuccessful prophylaxis, 2/14 (14 percent). Blood loss, transfusion requirements and post-operative complications did not differ significantly between the two prophylactic groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of blood transfusion on the incidence of deep vein thrombosis.

The incidence of postoperative deep vein thrombosis in 120 patients undergoing elective total hip replacement was determined venographically. Significantly more blood was administered to those developing thrombosis, particularly in the subgroups given general anaesthesia (P less than 0.05). There were no differences in the postoperative haemoglobin values in any of these groups. The distribution of other risk factors identified, namely previous thrombo-embolism, malignancy and previous vein surgery or injections did not influence this finding. The use of TED stockings (Kendall) was effective. It is suggested that greater emphasis should be placed on techniques that reduce blood loss such as regional anaesthesia and the posterior approach to the hip. Further research into the fluids used for blood volume maintenance will be beneficial.

High-dose computed tomography in the evaluation of low attenuation lesions in the neck.

Recent reports have established the clinical utility of computed tomography (CT) in the evaluation of jugular vein thrombosis. Other abnormalities of the soft tissues in the neck can mimic this condition. This study reviews the pertinent normal soft tissue and vascular anatomy of the neck and describes the use of high-dose CT in the evaluation of low attenuation lesions in this area. Various abnormalities are compared and contrasted, including cystic hygroma, neoplasm, abscess, and venous thrombosis.

Treatment of venous thrombosis in antithrombin III deficient patients with concentrates of antithrombin III.

Two patients with familial antithrombin III deficiency developed deep venous thrombosis of the lower limb. The diagnosis of venous thrombosis was made by the indium labelled platelet technique which also allowed for the daily assessment of thrombus size. Each patient received treatment with Warfarin, subcutaneous heparin, and infusions of antithrombin III concentrates. The authors conclude that infusions of antithrombin III concentrates may be of value in limiting the extent of acute thrombosis in patients with a severe deficiency of this protein and may help prevent pulmonary embolism. The haemorrhagic risk of continuing modest doses of heparin with high dose ATIII therapy appears small. In addition to its value in the diagnosis of venous thrombosis the indium platelet technique may give an early indication of thrombus extension and may thus indicate the effectiveness of treatment.