(Chest. 2001;120:1023-1024.)
© 2001
American College of Chest Physicians
A Diagnostic Dilemma of Fever and Back Pain Postpartum*
Davinder S. Jassal, MD;
Fredrik H. Fjeldsted, MD;
Edward R. Smith, MD and
Sat Sharma, MD, FCCP
*
From the Sections of General Internal Medicine (Drs. Jassal and Fjeldsted) and Respiratory Medicine (Drs. Smith and Sharma), Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
Correspondence to: Davinder S. Jassal MD, General Internal Medicine, GC4, Health Sciences Centre, 820 Sherbrook St, Winnipeg, Manitoba R3A 1R9, Canada; e-mail: umjassal{at}cc.umanitoba.ca
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Abstract
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A 26-year-old woman presented with fever, chills, and back pain 6
weeks postpartum. An infused CT scan of the abdomen and pelvis with IV
contrast confirmed septic pelvic vein thrombophlebitis as the
diagnosis. To the best of our knowledge, this is the first case report
describing such a massive thrombophlebitis extending from the superior
vena cava to the femoral vein inferiorly responsive to conventional
anticoagulation therapy. This exceptional case reminds us to entertain
septic pelvic thrombophlebitis in the differential of any patient who
presents with fever and back pain of unknown etiology.
Key Words: anticoagulation • septic pelvic thrombophlebitis
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Introduction
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Septic
pelvic thrombophlebitis is a rare complication of normal vaginal
delivery. The key to identifying this disease involves including it in
the differential diagnosis of a woman presenting with postpartum fever
and back pain. We describe a case of a 26-year-old woman who presented
with a massive septic pelvic thrombophlebitis extending from the
femoral vein to the superior vena cava responsive to combined
antimicrobial and anticoagulation therapy.
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Case Report
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A 26-year-old woman presented with a 3-day history of lower back
pain 6 weeks postpartum. During her pregnancy, she underwent multiple
attempts at an epidural for pain control, following which she had an
uncomplicated delivery. Three days prior to presentation, along with
fever and chills, she developed an acute onset of lower back
discomfort, predominantly on the left side. She was unable to ambulate
because of the weakness and pain in her left lower extremity. She
denied urinary or bowel symptoms.
The patient was febrile at 39.0°C and normotensive, yet demonstrated
no signs of systemic infection. Results of a cardiorespiratory
examination were unremarkable. On pelvic examination, the cervix and
uterus were nontender. On examination of the back, marked tenderness
along the left paraspinal muscle along the L4 to S1 vertebrae was
found. The result of a straight leg-raising test on the left side was
positive, with an otherwise normal neurologic examination of the lower
extremities. There was no calf or thigh swelling or tenderness.
The cell blood count revealed an elevated WBC of 14,000/µL with a
left shift. The electrolytes, urinalysis, and chest radiograph were
noncontributory. Because the possibility of endometritis and retained
tissues was entertained, the patient underwent vaginal ultrasound, the
findings of which were unremarkable. Additionally, MRI was performed to
exclude a spinal epidural abscess because of the number of attempts
taken to perform her epidural; findings were normal. The patient
subsequently underwent an infused CT of the abdomen and pelvis, with IV
contrast, which confirmed the diagnosis of septic pelvic
thrombophlebitis (Fig 1 ). The left iliofemoral, uterine, and ovarian veins were thrombosed with
clot extending to the inferior vena cava and superior vena cava. There
was no evidence of a pelvic abscess. Blood culture and endometrial
culture findings were negative, and results of a hypercoagulable
workup, including antithrombin, protein C and S deficiency, factor V
Leiden mutation, antiphospholipid, and homocysteine, were negative as
well.
The patient subsequently received treatment with clindamycin, 900
mg IV q8h, and gentamicin, 100 mg IV q8h, for 2 weeks, in addition to
anticoagulation with unfractionated heparin. The patient’s fever
abated within 48 h. Treatment with warfarin was initiated,
and the patient received anticoagulation therapy for a duration of 6
months. Results of spiral CT scan of the lung were negative for a
pulmonary embolus. A follow-up evaluation at 6 months after discharge
showed no evidence of reinfection nor recurrent thrombosis.
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Discussion
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Septic pelvic thrombophlebitis is a rare complication of normal
vaginal delivery, with a prevalence of 0.04 to 0.18%.1
A
MEDLINE review of the literature published between 1966 and 2000
revealed no reports of such a massive thrombophlebitis as in our case.
The largest thrombus reported2
involved extension to the
inferior vena cava. Our case is notable for the patient’s massive
thrombus extending from the superior vena cava to the femoral vein
inferiorly. Additionally, although septic pelvic thrombophlebitis
traditionally occurs 48 h to 4 weeks postpartum, our patient
presented at 6 weeks. The most common presenting symptoms include fever
(80%) and lower abdominal discomfort (67%), which may involve the
flank and back as well.3
The condition should be strongly
suspected with any postpartum or postoperative patient who continues to
spike temperatures despite antimicrobial therapy. The diagnosis is best
confirmed using abdominopelvic CT with IV contrast.4
Once
a diagnosis is made, the patient should receive prompt anticoagulation
therapy with heparin and parenteral antibiotics to cover
intra-abdominal anaerobes and Gram-negative organisms. Both the pain
and fever should abate within 3 to 4 days.5
The optimal
duration of anticoagulation is unknown, but with the extensive thrombus
presented in our case, we felt it necessary to continue anticoagulation
for at least 6 months. One should entertain the diagnosis of septic
pelvic thrombophlebitis in any patient presenting with fever and back
pain in the postpartum period.
Received for publication October 31, 2000.
Accepted for publication February 23, 2001.
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References
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Brown, T, Munsick, R (1971) Puerperial ovarian vein thrombophlebitis: a syndrome. Am J Obstet Gynecol 109,263-273[ISI][Medline]
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Magee, KP, Blanco, JD, Graham, JM (1993) Massive septic pelvic vein thrombophlebitis. Obstet Gynecol 82(4 Pt 2 Suppl),662-664[ISI][Medline]
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Dunnihoo, DR, Gallaspy, JW, Wise, RB, et al (1991) Postpartum ovarian vein thrombophlebitis: a review. Obstet Gynecol Surv 46,415-427[Medline]
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Twickler, DM, Setiawan, AT, Evans, RS, et al (1997) Imaging of puerperal septic thrombophlebitis: prospective comparison of MR imaging, CT, and sonography. AJR Am J Roentgenol 169,1039-1043[Abstract/Free Full Text]
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French, RA, Cole, C (1999) An "enigmatic" cause of back pain following regional anesthesia for caesarean section: septic pelvic vein thrombophlebitis. Anaesth Intensive Care 27,209-212[ISI][Medline]
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Abstract
Introduction
