Vol. 13 •Issue 7 • Page 21
Pain, Inflammation and a Nodule After IV Medication
Elizabeth, a 20-year-old college student, presented to the student health center where I work in January 2005. She reported having a painful vein on her right forearm since an intravenous medication injection a month prior. She had gone home over the Christmas break, become ill with gastroenteritis and sought medical treatment in the emergency department of a large teaching hospital near her home.
She received intravenous promethazine (Phenergan) and recalled that it burned considerably as it was administered. Elizabeth said that when she mentioned this to the staff member giving her the medication, the person told her she was “fine” and that she should apply warm compresses to the area if her discomfort persisted.
By the time she presented to the student health center, Elizabeth had been following this regimen for a month without relief and still had a tender, hard area on the vein above her right wrist. Her pain was constant and moderate in severity, made worse by contact and only slightly better with the warm compresses. She said she recently noticed a “knot” on her right arm just below her elbow.
Elizabeth had no fever, chills, shortness of breath, chest pain or cough. She reported no injury to the area. Her past medical history was unremarkable; she took no medications other than oral contraceptives and had no drug allergies. She was a nonsmoker.
Exam and Diagnostic Tests
On exam, Elizabeth was alert, afebrile and in no distress. On the dorsal aspect of her distal right forearm were two swollen, tender, inflamed areas along the track of her basilic vein. One area was approximately 4 cm long and just proximal to her right wrist. The other was approximately 1 cm long and just proximal to the first inflamed segment. I palpated a 0.5-cm, somewhat firm nodule on the dorsal proximal right forearm about 2 cm distal to the medial condyle. This appeared similar to the epitrochlear node but was not in the classic position for it.
I diagnosed Elizabeth with superficial phlebitis. Since she reported no history of gastrointestinal bleeding or ulcers, I prescribed oral naproxen sodium (Naprosyn) 500 mg every 12 hours with food. I also instructed her to take one 81-mg enteric-coated aspirin daily for its antiplatelet properties and wrote a referral for venous Doppler study to rule out thrombophlebitis. I instructed her to continue the warm compresses 4 to 6 times daily and to elevate her arm as much as possible. I further instructed her to report to the emergency department should she develop any shortness of breath, chest pain or hemoptysis. She was discharged home with further follow-up to be determined once the Doppler study results were in.
Elizabeth had her Doppler study a week later, and the results indicated a localized venous thrombosis in the right basilic vein just distal to the elbow. The radiologist noted that a superficial vein on the dorsum of the right hand demonstrated marked wall thickening but had good flow and compressibility, probably due to chronic thrombophlebitis. Based on these results, I referred Elizabeth to a local surgeon who evaluated her and instructed her to return for local excision in 2 months if the clot did not resolve.
Epidemiology
Superficial thrombophlebitis occurs frequently, yet it does not get much attention in the literature.1 This lack of attention is probably because the condition is often relatively mild and self-limiting. The list of risk factors is long (Table 1).
In contrast to deep vein thrombosis (DVT), which may result from hereditary blood disorders or chronic illness, superficial thrombophlebitis is typically the result of trauma (e.g., IV insertion and infusion of irritating medicines) or infection.1,2 This condition is common, occurs most frequently in young to middle-aged adults, and is slightly more frequent in women.1
Superficial thrombophlebitis does not typically cause significant morbidity or mortality unless the condition extends to the deep venous system. When this occurs, it can be the source of a pulmonary embolus (PE). Superficial thrombophlebitis is an acute inflammatory condition. Unlike DVT (which is typically not associated with inflammation), superficial thrombi adhere firmly to the inside of vessel walls and generally do not form emboli.3,4
Patients with thrombophlebitis frequently have alterations in one or more components of Virchow’s Triad: damage to the intimal wall of the vessel, venous stasis and altered coagulation.4 In this case, Elizabeth probably developed intimal damage as a result of the peripheral intravenous catheter. She had also received intravenous promethazine, and this nausea medication can induce the formation of antiphospholipid antibodies, another risk factor for thrombophlebitis.5
Differential Diagnosis
Signs and symptoms of superficial thrombophlebitis include tenderness, warmth and heat along the course of the affected vein, along with swelling in the affected extremity.1,3,5 The vein may have a palpable cord or knot. Table 2 lists differential diagnoses.
Examination should include the affected area, the regional lymph nodes and a cardiovascular exam if you suspect PE. Measurement of extremity circumference will objectively quantify any limb swelling. Measure at the same point on both extremities. I typically choose a bony landmark and measure from that landmark to the area of greatest circumference. I make sure that I measure from that same point on the other extremity. For example: “Arm circumference was 20 cm on the left and 18 cm on the right, measured 10 cm distal to the lateral condyles.”
Diagnostic tests distinguish thrombophlebitis from phlebitis and rule out thrombi of the deep venous system. Additional tests may be needed to evaluate for pulmonary embolism if DVT is present or you suspect PE. Several tests are available:2
Compression ultrasonography. This is the noninvasive test of choice; it uses sound waves to generate pictures inside an extremity and can identify superficial and deep thrombi. The patient in this case had this test.
Contrast venography. Although venogram is the gold standard, this is no longer the initial study of choice because of its invasive nature. The test involves threading a catheter into the affected vein and injecting contrast dye, which enables veins (and clots) to show up on x-ray.
Magnetic resonance imaging. Although not as widely used as venography and ultrasound, this may be useful when the patient cannot tolerate intravenous dye (e.g., dye allergy, pregnancy, renal failure).
While blood tests for coagulation disorders and blood dyscrasias are indicated in cases of DVT, my review of the literature did not find a similar recommendation for cases of uncomplicated superficial thrombophlebitis.
When PE is a concern, relevant diagnostic tests include ventilation or perfusion lung scanning, spiral CT of the chest and serum d-dimer level.
Treatment
Most cases of superficial thrombophlebitis are self-limiting and respond to conservative measures. Warm compresses and nonsteroidal anti-inflammatory drugs (NSAIDs) are mainstays of therapy.
While aspirin may be of benefit as an NSAID, its use as an antiplatelet agent is of little benefit because superficial thrombophlebitis is due to inflammation and fibrin clot, not platelet aggregation.1
Anticoagulants (e.g., heparin), while useful in the management of DVT, are not typically used in superficial cases of thrombophlebitis. Removal of an offending intravenous catheter and initiation of antibiotics are indicated in cases of thrombophlebitis caused by infection. Culture the catheter tip to identify the specific bacteria involved.
Follow-Up and Referral
Symptoms that do not resolve after 4 weeks require follow-up. In such cases, refer the patient to a general or vascular surgeon for excision of the clot under local anesthesia. Patients also should return if their symptoms worsen or if additional thrombi form, and they should seek emergency care for any signs or symptoms of pulmonary embolus (chest pain, shortness of breath, tachypnea, cough or hemoptysis).
References
1. Johnson G Jr. Superficial thrombophlebitis. eMedicine 2005. Available at: http://www.emedicine.com/med/topic3201.htm.
2. Lip GY, Pineo GF, Bauer KA. Patient information: venous thrombosis. UpToDate 2005. Available with subscription at: http://www.utdol.com.
3. Beers MH (ed.) Superficial thrombophlebitis. In The Merck Manual of Medical Information Online (2nd ed.) 2004. Available at: http://www.merck.com/mmhe/sec03/ch036/ch036c.html.
4. McMorran J, Crowther DC, McMorran S, et al. Superficial vein thrombosis. GPnotebook 2005. Available at: http://www.gpnotebook.co.uk/simplepage.cfm?ID=275447823.
5. Bauer KA, Lip GY. Evaluation of the patient with established venous thrombosis. UpToDate 2005. Available with subscription at: http://www.utdol.com.
Andrew Craig, NP, is a family nurse practitioner at The University of North Carolina-Charlotte’s Student Health Center and an NP in the U.S. Naval Reserve. He is also a member of the ADVANCE for Nurse Practitioners editorial advisory board and is the journal’s technology consultant.
Table 1: Risk Factors for Thrombophlebitis1,2,4
• Previous surgery
• Pregnancy
• Obesity
• Age older than 60 years
• Use of oral contraceptives, hormone replacement therapy or tamoxifen
• Immobilization, extended travel (“economy class syndrome”)
• Smoking
• Presence of an intravenous catheter
• Injection of caustic or irritating substances
• Previous thromboembolism
• Chronic medical conditions such as heart failure, renal disease or cancer
• Blood disorders such as polycythemia vera
• Elevated blood homocysteine; positive antiphospholipid antibodies
Table 2: Differential Diagnosis1
• Cellulitis
• Suppurative thrombophlebitis, a serious condition associated with intravenous infection and septicemia, manifested by purulence in the affected vein
• Migratory thrombophlebitis, recurrent, progressive thrombi along the course of a vein, usually in the lower extremities, associated with carcinoma
