Inferior vena cava thrombosis with septic shock case report and literature review

Inferior vena cava thrombosis with septic shock case report and literature review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Inferior vena cava thrombosis with septic shock case report and literature review Jinfeng Dai, Xuan Huang, Tongfei Feng, Shangao Li, Bin Lv This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3195685/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This case report provides a detailed description of a middle-aged male patient who presented with fatigue and decreased appetite whose medical history revealed type 2 diabetes mellitus, Whipple surgery and pulmonary tuberculosis. Upon admission, the patient presented with recurrent fever,septic shock and splenomegaly. Extensive diagnostic workup, including blood tests, imaging studies and culture, was performed to investigate the underlying cause. Inferior vena cava septic thrombophlebitis was finally diagnosed. The patient showed improvement and was discharged after receiving a full course of high-dose antibiotics and heparin treatment. Inferior vena cava septic thrombophlebitis septic shock thrombosis FUO Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Case report A 54-year-old man was admitted to the hospital on July 13, 2022, complaining of fatigue and decreased appetite for over two weeks. He experienced loose stools and defecated once a day during the onset of the disease. The patient had a history of type 2 diabetes for 15 years and had undergone Whipple surgery more than 10 years ago, although the pathological results were unavailable. He had also previously contracted tuberculosis but had successfully recovered after receiving regular treatment. Shortly after admission, the patient's temperature increased from 37.8 ℃ to 40.9 ℃, accompanied by an elevation in heart rate(HR) from 129 bpm to 143 bpm. He experienced mild tightness in the chest, shortness of breath, and coughing with white phlegm. Diagnostic tests revealed sinus tachycardia on electrocardiogram, along with abnormal blood parameters: WBC 7.5× 10^9/L, Neutrophils 96.8%, hemoglobin 93g/L, PLT 103×10^9/L, CRP 237.26mg/L, and lactate 2.80mmol/L. Cardiac troponin, myocardial enzyme spectrum, electrolytes, and renal function showed no significant abnormalities.Chest CT scans showed scattered infectious lesions in both lungs, residual lesions with bronchial dilation, an enlarged heart with pericardial effusion, and widened pulmonary arteries(Fig. 1 ). The patient was diagnosed with pneumonia complicated by septic shock. Diagnosed with pneumonia complicated by septic shock, the patient received rapid fluid infusion and was prescribed acetaminophen and cefoperazone sulbactam. However, despite treatment, the patient's high fever, chills, elevated heart rate, and unstable blood pressure persisted. He was promptly transferred to the Intensive Care Unit (ICU) at 2:30am the following day. In the ICU, an echocardiography revealed a hypoechoic mass approximately 1.3 * 3.5cm near the right atrium entrance within the posterior segment of the inferior vena cava (IVC), suggesting thrombosis(Vedio 1). Subsequent tests ruled out tuberculosis recurrence. An enhanced abdominal CT scan indicated postoperative changes in the stomach,pancreatic duct stent left over from surgery, slight gastric wall thickening, fatty liver, spleen enlargement, abdominal fluid accumulation, peritoneal mesenteric space changes, colonic liver curvature wall thickening and edema, and insufficient filling of the hepatic segment of the IVC(Fig. 2 ). Vedio1:A hypoechoic mass of approximately 1.3 * 3.5cm in the posterior hepatic segment of the inferior vena cava, swaying with blood flow. After treatment with Meropenem and heparin, the patient returned to the general ward on the fifth day and stopped using heparin. Two weeks later, the patient was considered "recovered" with normal body temperature and echocardiography(Fig. 3). However, four days after normalizing body temperature, he experienced another high fever episode, accompanied by elevated PCT, CRP, WBC, and neutrophil levels. Follow-up echocardiography did not reveal significant abnormalities. CT venography (CTV) of the IVC showed worsening thrombosis extending into the right hepatic vein(Fig. 4 ). Blood culture results were positive for Pseudomonas aeruginosa and fecal Enterococcus. Based on the medical history and multidisciplinary discussions, the diagnosis is septic thrombophlebitis of the IVC(IVCST). The patient received a combination of piperacillin-tazobactam (4.5g q6h), amikacin (0.2g q12h), and heparin based on drug sensitivity tests.After three weeks, the patient recovered and was discharged. Following discharge, the patient continued taking 60mg of idoxaban orally every day. During the eleven-month follow-up period, the patient did not experience further episodes of fever. A follow-up CT scan of the IVC indicated a significant reduction in the size of the IVC thrombus compared to before(Fig. 5 ). Discussion IVCST is an uncommon condition that is often associated with surgical procedures, implantation of vascular foreign bodies, intravenous drug use, and tumor invasion 1 – 7 . In one reported case, the condition was secondary to Crohn's disease 8 . Recurrence of septic thrombophlebitis may be influenced by diabetes 4 . Pathogens causing IVCST can vary and include both bacteria and fungi 1 – 8 . In the course of the disease, different pathogens may be cultured at different times in the same patient. Reported cases have identified bacteria such as Enterococcus, Staphylococcus, Streptococcus, Klebsiella, Bacteroides, Actinomyces, and Enterobacteriaceae coli, as well as Candida as the most common gram-positive bacteria and fungi, respectively 1 – 8 . Buitrago AP et al. reported a case of an infant with IVC thrombosis and infective endocarditis (IE) resulting from umbilical vein catheterization 5 . Another case reported by Işik M et al. described IVC thrombus in patients originating from intestinal diverticulum perforation, accompanied by IE. Given the close proximity of the IVC thrombus to the right atrial entrance, Our patient might also have suffered from IE without immediate treatment. Enhanced CT scan of the abdomen, particularly CT scan of the IVC, is commonly used for diagnosing IVCST. During the venous phase, it typically presents as IVC widening with low-density thrombi surrounded by high-density vascular walls. In some cases, extremely low-density shadows resembling gas can be observed within the low-density thrombi 9 . CT scan is also valuable in identifying the source of infection 9 . If the thrombus has been present for a long time, sonography will show high echogenicity in the IVC with posterior acoustic shadows 10 . In the case of our patient, who had a recent thrombosis, ultrasound revealed flocculent hypoechogenicity floating with the blood flow. Echocardiogram, as mentioned earlier, aids in the diagnosis of IVCST involving the right atrium. Twickler DM et al. compared the diagnostic value of CT, MR, and sonography for postpartum septic thrombophlebitis and found that both CT and MR had higher sensitivity and specificity than sonography 11 . However, no such study has been conducted specifically for diagnosing IVCST. In recent years, PET-CT has shown promise in the diagnosis of septic thrombophlebitis, with greater FDG uptake observed in infectious thrombosis compared to non-infectious thrombosis 12 – 13 . The primary treatment for septic thrombophlebitis remains antibiotics. In most studies, antibiotic selection is based on in vitro drug sensitivity tests. As mentioned earlier, Gram-positive bacteria are commonly implicated, and aminoglycosides and penicillin are frequently used 1–2,5−7 . For Candida infections, carbapenem, voriconazole, and amphotericin B can be utilized 8 , 14 . The use of anticoagulants in septic thrombophlebitis is still a subject of controversy. Most studies employ heparin and warfarin for anticoagulation 1 – 2 , 5 – 7 . Brown CE et al. compared the prognosis of patients with pelvic septic thrombophlebitis treated with and without heparin and found no significant differences in fever duration and hospital stay between the two groups. However, this study had a small sample size, and its applicability to IVCST is uncertain. Further research is required. Surgery and interventional therapy are still viable options for treating septic thrombophlebitis when antibiotics and anticoagulation have been proven ineffective 15 . In conclusion, vigilance is necessary for infectious thrombophlebitis in cases of unexplained fever and sepsis. CT, MR, sonography, and even PET-CT can assist in the diagnosis of septic thrombophlebitis. Multiple blood cultures and in vitro drug sensitivity tests contribute to pathogen identification and screening for effective drugs. Adequate antibiotic treatment for an appropriate duration is essential. Surgery and interventional therapy remain viable options when antibiotics and anticoagulation treatment are unsuccessful. Declarations Acknowledgment We extend our appreciation to all the doctors from The first Affiliated Hospital Of Zhejiang Chinese Medical University who participated in the MDT discussion, including Zhirong Zhang from ICU, Tingzhen Chenfrom Respiratory Department, Lin Yang from Imaging Department, Li Xia from Rheumatology and Immunology Department, Shenjie Chenfrom Cardiology Department, Qiang Zhu from Infection Department, and Qinghong Yu from Hematology Department. Ethical Approval An ethics statement is not applicable because this study is a case report not clinical study. The patient has verbally agreed to the publication of this article. Competing interests I declare that the authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper. Authors' contributions Jinfeng Dai wrote this article, Xuan Huang searched relevant literatures for septic thrombophlebitis, Tongfei Feng collected patient information, Haijun Cao edited figures, Li Shangao, as the medical team leader, managed the entire process of the patient, and Lv Bin provided the article ideas and revised the article. Funding We thank the Zhejiang Natural Science Foundation Committee (grant no. Q20H030019) and Zhejiang Administration of Traditional Chinese Medicine(grant no. 2023ZF101) for the financial support. Availability of data and materials ALL the diagnostic workup, including blood tests, imaging studies and culture, and detail medical history of the patient can be submitted if it is necessary. References Talaie Tara,Drucker Charles,Aicher Brittany,et al. Endovascular Thrombectomy of Septic Thrombophlebitis of the Inferior Vena Cava: Case Report and Review of the Literature[J]. Vascular and endovascular surgery,2018, 52(8):641-647. Meda M S,Lopez A J,Guyot A. Candida inferior vena cava filter infection and septic thrombophlebitis[J]. The British journal of radiology,2007,80(950):e48-49. Sashi R,Ito I,Watarai J,et al. Thrombophlebitis of the inferior vena cava involving the retroperitoneum with Crohn's disease: MR demonstration.[J]. Magnetic resonance imaging,1997,15(9):1099-1101. Klein D,Kvapil M,Růzek V. Thrombosis of the inferior vena cava--an unusual cause of a chronic septic condition in a female patient with type 1 diabetes mellitus.[J]. Casopis lekaru ceskych,1993,132(14):434-436. Buitrago AP , Zuluag NAV, Murillo AFU,et al. Inferior vena cava thrombosis and endocarditis in a premature patient: case report.Rev Chil Pediatr. 2014;85(6):708-713. Işik M,Çinar E,Cemal KM,st al. A confusing case: pulmonary lesions including cavities, isolated left heart endocarditis and inferior vena cava thrombosis in a patient with perforated diverticulitis.[J]. Rheumatology international,2013,33(8):2179-2181. Burgmans MC,Rommes JH,Spronk PE,et al. Septic thrombosis of the inferior vena cava treated with percutaneous mechanical thrombectomy.[J]. Journal of vascular and interventional radiology : JVIR,2006,17(10):1697-1702. Ashkenazi S,Pickering L K,Robinson L H. Diagnosis and management of septic thrombosis of the inferior vena cava caused by Candida tropicalis[J]. The Pediatric infectious disease journal,1990,9(6):446-447. Schmitz L, Jeffrey RB, Palubinskas AJ, et al.CT demonstration of septic thrombosis of the inferior vena cava[J].J Comput Assist Tomogr. 1981,5(2):259-261. Bank ER , Glazer GM. Ultrasonographic detection of infected thrombus in the inferior vena cava[J].J Ultrasound Med. 1984,3(12):567-568. Twickler DM, Setiawan AT, Evans RS, et al.Imaging of puerperal septic thrombophlebitis: prospective comparison of MR imaging, CT, and sonography.AJR Am J Roentgenol. 1997,169(4):1039-1043. Harnett P, Jain S.Lesson of the month 1: Spontaneous septic thrombophlebitis presenting with bacteraemia diagnosed by PET-CT scan. Clinical Medicine.2017,17(5): 471–472. Bleeker-Rovers CP, Jager G, Tack CJ, et al. F-18-flfluorodeoxyglucose positron emission tomography leading to a diagnosis of septic thrombophlebitis of the portal vein: description of tion of a case history and review of the literature.J Intern Med. 2004,255(3):419-423. Pan SC, Hsieh SM, Chang SC, et al. Septic Candida krusei thrombophlebitis of inferior vena cava with persistent fungemia successfully treated by new antifungal agents.Med Mycol.2005,43(8):731-734. Suchý T,Brzek V,Bures J,Heger L. Post-cannulation purulent thrombophlebitis of the inferior vena cava: preoperative diagnosis using CT and successful surgical treatment.[J]. Rozhledy v chirurgii : mesicnik Ceskoslovenske chirurgicke spolecnosti,1984,63(12):856-860. Video Video 1 is not available with this version. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3195685","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":221299140,"identity":"1140c306-6cfc-482c-ac92-9c6024cea149","order_by":0,"name":"Jinfeng Dai","email":"","orcid":"","institution":"The First Affiliated Hospital Of Zhejiang Chinese Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jinfeng","middleName":"","lastName":"Dai","suffix":""},{"id":221299142,"identity":"90911633-0d04-4d16-9243-094c71fbd1ef","order_by":1,"name":"Xuan Huang","email":"","orcid":"","institution":"The First Affiliated Hospital Of Zhejiang Chinese Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xuan","middleName":"","lastName":"Huang","suffix":""},{"id":221299143,"identity":"31cb1e97-2e7f-49ea-86a8-2ca255797b62","order_by":2,"name":"Tongfei Feng","email":"","orcid":"","institution":"The First Affiliated Hospital Of Zhejiang Chinese Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tongfei","middleName":"","lastName":"Feng","suffix":""},{"id":221299144,"identity":"1f862e7c-f8b3-4f5a-8f33-ad71251b1453","order_by":3,"name":"Shangao Li","email":"","orcid":"","institution":"The First Affiliated Hospital Of Zhejiang Chinese Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shangao","middleName":"","lastName":"Li","suffix":""},{"id":221299145,"identity":"e79f589d-f23d-4c80-9228-b60e0d451494","order_by":4,"name":"Bin Lv","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBACAwYehgMMFUDWASB6QLyWM1AtCcRqYWBsg2hhIE6LRO7Bw4XztsnxXTv8EGiLnZxuA/MzvA40kMhLODxz221jydtpBkAtycZmB9jMDfBq4TljcJh32+3EDbcTQFoOJG47wMMmQVjLnNv1G26nfyBSC3sPUEsD0IrbOcTawt6XcJjn2G3DmbdzCg4kGAD9cpjNDK8W+2bew595am7L891O3/zhQ4WdnNnx5md4taBbCsTMJKgfBaNgFIyCUYAdAAD+mE9Ep5zv8gAAAABJRU5ErkJggg==","orcid":"","institution":"The First Affiliated Hospital Of Zhejiang Chinese Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Lv","suffix":""}],"badges":[],"createdAt":"2023-07-23 04:44:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3195685/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3195685/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":40835829,"identity":"a40dc7c9-4631-4ed3-99d6-c71a58021e69","added_by":"auto","created_at":"2023-07-31 17:36:13","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":180840,"visible":true,"origin":"","legend":"\u003cp\u003eChest CT on July 13, 2022:scattered infectious lesions in both lungs（black arrow）, residual lesions with bronchial dilation(red arrow), an enlarged heart with pericardial effusion（white arrow）, and widened pulmonary arteries(yellow arrow).\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3195685/v1/dd1ee7df0cdafc06530b5fe6.jpg"},{"id":40835831,"identity":"d7cadd47-f801-4019-b2f9-b0cd5a03d88f","added_by":"auto","created_at":"2023-07-31 17:36:14","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":224524,"visible":true,"origin":"","legend":"\u003cp\u003eAbdominal CT scan on July 15, 2022: (a) Pancreatic duct stent left over from surgery(Red arrow),fatty liver(white arrow), spleen enlargement(yellow arrow); (b) Colonic liver curvature wall thickening and edema(white arrow), abdominal fluid accumulation(red arrow), peritoneal mesenteric space changes(yellow arrow); (c)Insufficient filling of the hepatic segment of the IVC(white arrow) and abdominal fluid accumulation(red arrow) .\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3195685/v1/04449831a7ebbd83c92d8c9e.jpg"},{"id":40835996,"identity":"b77c7686-4275-4ff3-8ba2-e1df13a60ab6","added_by":"auto","created_at":"2023-07-31 17:44:13","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":73227,"visible":true,"origin":"","legend":"\u003cp\u003eEchocardiography on July 22, 2022: No thrombus was observed within the visible segment of the IVC.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3195685/v1/c106f8239f5bed601d8b817e.jpg"},{"id":40835830,"identity":"8e69fee3-e98d-4c43-8abc-d3329c68ca4a","added_by":"auto","created_at":"2023-07-31 17:36:13","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":188488,"visible":true,"origin":"","legend":"\u003cp\u003eCTV of IVC scan on August 8, 2022: Enlarged thrombosis in IVC(white arrow) extending into the right hepatic vein(red arrow). Exudation is evident surrounding the affected veins(black arrow).\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3195685/v1/bea2ed329682744811ccde0c.jpg"},{"id":40835827,"identity":"01318e97-4c82-4bea-baf1-ee8fdbc4f668","added_by":"auto","created_at":"2023-07-31 17:36:13","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":259622,"visible":true,"origin":"","legend":"\u003cp\u003eCTV of IVC scan on July 22, 2023,: A significant reduction in the size of thrombus compared to figure 4(white and red arrow). No exudation is observed around the affected veins.\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3195685/v1/7a6b05968aed40b9aec112cb.jpg"},{"id":48823306,"identity":"2b6476f3-513d-4507-82f6-fb2a1eb0b109","added_by":"auto","created_at":"2023-12-26 22:37:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":480599,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3195685/v1/d94b624a-6500-4730-81ee-308cc88ea765.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Inferior vena cava thrombosis with septic shock case report and literature review","fulltext":[{"header":"Case report","content":"\u003cp\u003eA 54-year-old man was admitted to the hospital on July 13, 2022, complaining of fatigue and decreased appetite for over two weeks. He experienced loose stools and defecated once a day during the onset of the disease. The patient had a history of type 2 diabetes for 15 years and had undergone Whipple surgery more than 10 years ago, although the pathological results were unavailable. He had also previously contracted tuberculosis but had successfully recovered after receiving regular treatment.\u003c/p\u003e\n\u003cp\u003eShortly after admission, the patient's temperature increased from 37.8 ℃ to 40.9 ℃, accompanied by an elevation in heart rate(HR) from 129 bpm to 143 bpm. He experienced mild tightness in the chest, shortness of breath, and coughing with white phlegm. Diagnostic tests revealed sinus tachycardia on electrocardiogram, along with abnormal blood parameters: WBC 7.5\u0026times; 10^9/L, Neutrophils 96.8%, hemoglobin 93g/L, PLT 103\u0026times;10^9/L, CRP 237.26mg/L, and lactate 2.80mmol/L. Cardiac troponin, myocardial enzyme spectrum, electrolytes, and renal function showed no significant abnormalities.Chest CT scans showed scattered infectious lesions in both lungs, residual lesions with bronchial dilation, an enlarged heart with pericardial effusion, and widened pulmonary arteries(Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The patient was diagnosed with pneumonia complicated by septic shock. Diagnosed with pneumonia complicated by septic shock, the patient received rapid fluid infusion and was prescribed acetaminophen and cefoperazone sulbactam. However, despite treatment, the patient's high fever, chills, elevated heart rate, and unstable blood pressure persisted. He was promptly transferred to the Intensive Care Unit (ICU) at 2:30am the following day.\u003c/p\u003e\n\u003cp\u003eIn the ICU, an echocardiography revealed a hypoechoic mass approximately 1.3 * 3.5cm near the right atrium entrance within the posterior segment of the inferior vena cava (IVC), suggesting thrombosis(Vedio 1). Subsequent tests ruled out tuberculosis recurrence. An enhanced abdominal CT scan indicated postoperative changes in the stomach,pancreatic duct stent left over from surgery, slight gastric wall thickening, fatty liver, spleen enlargement, abdominal fluid accumulation, peritoneal mesenteric space changes, colonic liver curvature wall thickening and edema, and insufficient filling of the hepatic segment of the IVC(Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eVedio1:A hypoechoic mass of approximately 1.3 * 3.5cm in the posterior hepatic segment of the inferior vena cava, swaying with blood flow.\u003c/p\u003e\n\u003cp\u003eAfter treatment with Meropenem and heparin, the patient returned to the general ward on the fifth day and stopped using heparin. Two weeks later, the patient was considered \"recovered\" with normal body temperature and echocardiography(Fig.\u0026nbsp;3). However, four days after normalizing body temperature, he experienced another high fever episode, accompanied by elevated PCT, CRP, WBC, and neutrophil levels. Follow-up echocardiography did not reveal significant abnormalities. CT venography (CTV) of the IVC showed worsening thrombosis extending into the right hepatic vein(Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). Blood culture results were positive for Pseudomonas aeruginosa and fecal Enterococcus. Based on the medical history and multidisciplinary discussions, the diagnosis is septic thrombophlebitis of the IVC(IVCST). The patient received a combination of piperacillin-tazobactam (4.5g q6h), amikacin (0.2g q12h), and heparin based on drug sensitivity tests.After three weeks, the patient recovered and was discharged. Following discharge, the patient continued taking 60mg of idoxaban orally every day.\u003c/p\u003e\n\u003cp\u003eDuring the eleven-month follow-up period, the patient did not experience further episodes of fever. A follow-up CT scan of the IVC indicated a significant reduction in the size of the IVC thrombus compared to before(Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIVCST is an uncommon condition that is often associated with surgical procedures, implantation of vascular foreign bodies, intravenous drug use, and tumor invasion \u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. In one reported case, the condition was secondary to Crohn's disease\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Recurrence of septic thrombophlebitis may be influenced by diabetes \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Pathogens causing IVCST can vary and include both bacteria and fungi \u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. In the course of the disease, different pathogens may be cultured at different times in the same patient. Reported cases have identified bacteria such as Enterococcus, Staphylococcus, Streptococcus, Klebsiella, Bacteroides, Actinomyces, and Enterobacteriaceae coli, as well as Candida as the most common gram-positive bacteria and fungi, respectively\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Buitrago AP et al. reported a case of an infant with IVC thrombosis and infective endocarditis (IE) resulting from umbilical vein catheterization\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Another case reported by Işik M et al. described IVC thrombus in patients originating from intestinal diverticulum perforation, accompanied by IE. Given the close proximity of the IVC thrombus to the right atrial entrance, Our patient might also have suffered from IE without immediate treatment.\u003c/p\u003e \u003cp\u003eEnhanced CT scan of the abdomen, particularly CT scan of the IVC, is commonly used for diagnosing IVCST. During the venous phase, it typically presents as IVC widening with low-density thrombi surrounded by high-density vascular walls. In some cases, extremely low-density shadows resembling gas can be observed within the low-density thrombi\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. CT scan is also valuable in identifying the source of infection \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. If the thrombus has been present for a long time, sonography will show high echogenicity in the IVC with posterior acoustic shadows \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. In the case of our patient, who had a recent thrombosis, ultrasound revealed flocculent hypoechogenicity floating with the blood flow. Echocardiogram, as mentioned earlier, aids in the diagnosis of IVCST involving the right atrium. Twickler DM et al. compared the diagnostic value of CT, MR, and sonography for postpartum septic thrombophlebitis and found that both CT and MR had higher sensitivity and specificity than sonography\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. However, no such study has been conducted specifically for diagnosing IVCST. In recent years, PET-CT has shown promise in the diagnosis of septic thrombophlebitis, with greater FDG uptake observed in infectious thrombosis compared to non-infectious thrombosis \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe primary treatment for septic thrombophlebitis remains antibiotics. In most studies, antibiotic selection is based on in vitro drug sensitivity tests. As mentioned earlier, Gram-positive bacteria are commonly implicated, and aminoglycosides and penicillin are frequently used\u003csup\u003e1\u0026ndash;2,5\u0026minus;7\u003c/sup\u003e. For Candida infections, carbapenem, voriconazole, and amphotericin B can be utilized\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. The use of anticoagulants in septic thrombophlebitis is still a subject of controversy. Most studies employ heparin and warfarin for anticoagulation\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Brown CE et al. compared the prognosis of patients with pelvic septic thrombophlebitis treated with and without heparin and found no significant differences in fever duration and hospital stay between the two groups. However, this study had a small sample size, and its applicability to IVCST is uncertain. Further research is required. Surgery and interventional therapy are still viable options for treating septic thrombophlebitis when antibiotics and anticoagulation have been proven ineffective \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn conclusion, vigilance is necessary for infectious thrombophlebitis in cases of unexplained fever and sepsis. CT, MR, sonography, and even PET-CT can assist in the diagnosis of septic thrombophlebitis. Multiple blood cultures and in vitro drug sensitivity tests contribute to pathogen identification and screening for effective drugs. Adequate antibiotic treatment for an appropriate duration is essential. Surgery and interventional therapy remain viable options when antibiotics and anticoagulation treatment are unsuccessful.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgment\u003c/p\u003e\n\u003cp\u003eWe extend our appreciation to all the doctors from The first Affiliated Hospital Of Zhejiang Chinese Medical University who participated in the MDT discussion, including Zhirong Zhang from ICU, Tingzhen Chenfrom Respiratory Department, Lin Yang from Imaging Department, Li Xia from Rheumatology and Immunology Department, Shenjie Chenfrom Cardiology Department, Qiang Zhu from Infection Department, and Qinghong Yu from Hematology Department.\u003c/p\u003e\n\u003cp\u003eEthical Approval\u003c/p\u003e\n\u003cp\u003eAn ethics statement is not applicable because this study is a case report not clinical study. The patient has verbally agreed to the publication of this article.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eI declare that the authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eJinfeng Dai wrote this article, Xuan Huang searched relevant literatures for septic thrombophlebitis, Tongfei Feng collected patient information, Haijun Cao edited figures, Li Shangao, as the medical team leader, managed the entire process of the patient, and Lv Bin provided the article ideas and revised the article.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eWe thank the Zhejiang Natural Science Foundation Committee (grant no. Q20H030019) and Zhejiang Administration of Traditional Chinese Medicine(grant no. 2023ZF101) for the financial support.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eALL the diagnostic workup, including blood tests, imaging studies and culture, and detail medical history of the patient can be submitted if it is necessary.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTalaie Tara,Drucker Charles,Aicher Brittany,et al. Endovascular Thrombectomy of Septic Thrombophlebitis of the Inferior Vena Cava: Case Report and Review of the Literature[J]. Vascular and endovascular surgery,2018, 52(8):641-647.\u003c/li\u003e\n\u003cli\u003eMeda M S,Lopez A J,Guyot A. Candida inferior vena cava filter infection and septic thrombophlebitis[J]. The British journal of radiology,2007,80(950):e48-49.\u003c/li\u003e\n\u003cli\u003eSashi R,Ito I,Watarai J,et al. Thrombophlebitis of the inferior vena cava involving the retroperitoneum with Crohn\u0026apos;s disease: MR demonstration.[J]. Magnetic resonance imaging,1997,15(9):1099-1101.\u003c/li\u003e\n\u003cli\u003eKlein D,Kvapil M,Růzek V. Thrombosis of the inferior vena cava--an unusual cause of a chronic septic condition in a female patient with type 1 diabetes mellitus.[J]. Casopis lekaru ceskych,1993,132(14):434-436.\u003c/li\u003e\n\u003cli\u003eBuitrago AP , Zuluag NAV, Murillo AFU,et al. Inferior vena cava thrombosis and endocarditis in a premature patient: case report.Rev Chil Pediatr. 2014;85(6):708-713.\u003c/li\u003e\n\u003cli\u003eIşik M,\u0026Ccedil;inar E,Cemal KM,st al. A confusing case: pulmonary lesions including cavities, isolated left heart endocarditis and inferior vena cava thrombosis in a patient with perforated diverticulitis.[J]. Rheumatology international,2013,33(8):2179-2181.\u003c/li\u003e\n\u003cli\u003eBurgmans MC,Rommes JH,Spronk PE,et al. Septic thrombosis of the inferior vena cava treated with percutaneous mechanical thrombectomy.[J]. Journal of vascular and interventional radiology : JVIR,2006,17(10):1697-1702.\u003c/li\u003e\n\u003cli\u003eAshkenazi S,Pickering L K,Robinson L H. Diagnosis and management of septic thrombosis of the inferior vena cava caused by Candida tropicalis[J]. The Pediatric infectious disease journal,1990,9(6):446-447.\u003c/li\u003e\n\u003cli\u003eSchmitz L, Jeffrey RB, Palubinskas AJ, et al.CT\u0026ensp;demonstration\u0026ensp;of\u0026ensp;septic\u0026ensp;thrombosis\u0026ensp;of the\u0026ensp;inferior\u0026ensp;vena\u0026ensp;cava[J].J Comput Assist Tomogr. 1981,5(2):259-261.\u003c/li\u003e\n\u003cli\u003eBank ER , Glazer GM. Ultrasonographic detection of infected thrombus in the inferior vena cava[J].J Ultrasound Med. 1984,3(12):567-568.\u003c/li\u003e\n\u003cli\u003eTwickler DM, Setiawan AT, Evans RS, et al.Imaging of puerperal septic thrombophlebitis: prospective comparison of MR imaging, CT, and sonography.AJR Am J Roentgenol. 1997,169(4):1039-1043.\u003c/li\u003e\n\u003cli\u003eHarnett P, Jain S.Lesson of the month 1: Spontaneous septic thrombophlebitis presenting with bacteraemia diagnosed by PET-CT scan. Clinical Medicine.2017,17(5): 471\u0026ndash;472.\u003c/li\u003e\n\u003cli\u003eBleeker-Rovers CP, Jager G, Tack CJ, et al. F-18-flfluorodeoxyglucose positron emission tomography leading to a diagnosis of septic thrombophlebitis of the portal vein: description of tion of a case history and review of the literature.J Intern Med. 2004,255(3):419-423.\u003c/li\u003e\n\u003cli\u003ePan SC, Hsieh SM, Chang SC, et al. Septic Candida krusei thrombophlebitis of inferior vena cava with persistent fungemia successfully treated by new antifungal agents.Med Mycol.2005,43(8):731-734.\u003c/li\u003e\n\u003cli\u003eSuch\u0026yacute; T,Brzek V,Bures J,Heger L. Post-cannulation purulent thrombophlebitis of the inferior vena cava: preoperative diagnosis using CT and successful surgical treatment.[J]. Rozhledy v chirurgii : mesicnik Ceskoslovenske chirurgicke spolecnosti,1984,63(12):856-860.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Video","content":"\u003cp\u003eVideo 1 is not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Inferior vena cava, septic thrombophlebitis, septic shock, thrombosis, FUO","lastPublishedDoi":"10.21203/rs.3.rs-3195685/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3195685/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis case report provides a detailed description of a middle-aged male patient who presented with fatigue and decreased appetite whose medical history revealed type 2 diabetes mellitus, Whipple surgery and pulmonary tuberculosis. Upon admission, the patient presented with recurrent fever,septic shock and splenomegaly. Extensive diagnostic workup, including blood tests, imaging studies and culture, was performed to investigate the underlying cause. Inferior vena cava septic thrombophlebitis was finally diagnosed. The patient showed improvement and was discharged after receiving a full course of high-dose antibiotics and heparin treatment.\u003c/p\u003e","manuscriptTitle":"Inferior vena cava thrombosis with septic shock case report and literature review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-07-31 17:36:08","doi":"10.21203/rs.3.rs-3195685/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8c0d95f8-fcf8-4fff-825c-297747dafa91","owner":[],"postedDate":"July 31st, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-12-26T22:29:15+00:00","versionOfRecord":[],"versionCreatedAt":"2023-07-31 17:36:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3195685","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3195685","identity":"rs-3195685","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}