Intraluminal Gas in Deep Vein Thrombosis Associated with Rhodotorula mucilaginosa Fungemia and Prevotella intermedia Bacteremia: A Unique Clinical Case Report and Literature Overview

Intraluminal Gas in Deep Vein Thrombosis Associated with Rhodotorula mucilaginosa Fungemia and Prevotella intermedia Bacteremia: A Unique Clinical Case Report and Literature Overview | 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 Intraluminal Gas in Deep Vein Thrombosis Associated with Rhodotorula mucilaginosa Fungemia and Prevotella intermedia Bacteremia: A Unique Clinical Case Report and Literature Overview Nima Shariatzadeh, Suchit Chidurala, Samuel Nesemann This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5545236/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Sep, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted 32 You are reading this latest preprint version Abstract Intravenous drug use (IVDU) is associated with multiple complications, including thrombus and infection with rare pathogens. Here, we present a unique case of septic thrombophlebitis with gas present within the lumen of the thrombus that was identified from an otherwise unassuming wound in a point-of-care ultrasound. In conjunction with past literature, this finding supports the presence of intraluminal gas as a strong indicator of septic thrombophlebitis. Furthermore, the patient’s polymicrobial infection with Rhodotorula mucilaginosa and Prevotella intermedia expands the types of pathogens that should be suspected in IVDU-related infections. This case is the first reported infection of an immunocompetent IVDU patient with Rhodotorula mucilaginosa. Though rare, greater attention should be paid to this emerging pathogen in IVDU. This case highlights the importance of a low threshold for using a point-of-care ultrasound in patients with IVDU or other risk factors for complex infections. septic thrombophlebitis case report IV drug use Rhodotorula mucilaginosa intraluminal gas Figures Figure 1 Figure 2 Figure 3 Introduction Intravenous drug usage (IVDU) has significantly increased in the United States with about 3.5 million individuals injecting drugs. 1 IVDU poses a significant health burden as it is often associated with increased mortality and morbidity. Degenhardt et al. report that 15% of people who inject drugs live with HIV, 39% have HCV infection, 18.5% have recently overdosed, and 32% have had a skin or soft tissue infection. 2 The most common bacterial infections associated with IVDU originate from skin, oral cavity, or environment. 3 , 4 Oral microbiota, specifically, can cause infection in IVDU as poor hygiene practices like needle licking are conducted by up to one third of people injecting drugs. 4 , 5 Prevotella intermedia is an obligate anaerobic gram-negative bacilli that is normally found in the oral cavity and can rarely cause infection in IVDU. 6 , 7 P. intermedia is mostly associated with periodontal disease, and there is very little literature regarding bacteremia caused by it, especially in the case of IVDU. 8 – 10 Fungal infections can also cause serious complications in IVDU. 11 While mostly associated with intravenous catheter placement, Rhodotorula mucilaginosa is an environmental basidiomycete yeast that can colonize the skin, respiratory, and gastrointestinal tracts. 12 Notably, it has been found in tap water and common household appliances. 13 R. mucilaginosa is an emerging pathogen with high resistance profile and considerable morbidity and mortality, particularly in immunocompromised hosts. 14 , 15 Few cases of R. mucilaginosa have been reported in immunocompetent individuals, and, to our knowledge, no case of R. mucilaginosa has been reported in association with IVDU. 16 , 17 Given the highly resistant nature of R. mucilaginosa , understanding previously successful treatments is crucial for managing this emerging pathogen. IVDU can also cause deep vein thrombosis (DVT). DVT can be caused by many factors including reduced blood flow, increased venous pressure, mechanical injury to the vein by various injuries like trauma or IVDU, increased blood viscosity, and increased coagulation risk either acquired or genetic. 18 Szlaszynska et al. reported the prevalence of DVT in people injecting drugs was 29% while 15% of all DVT cases were associated with IVDU. 19 DVT can be asymptomatic but typically presents with pain, warmth, redness, and swelling of the lower extremity with an increased incidence after 40 years of age. 20 However, DVT in IVDU usually differs in presentation with a higher incidence in younger patients and poorer outcomes/complications like slower recovery, recurrent venous thromboembolism, and a longer hospital stay, all of which increase the risk of morbidity, mortality, reduced productivity, and economic burden. 19 , 21 DVT can also occur in the setting of a bacterial or fungal infection, which is referred to as septic thrombophlebitis (STP). STP is associated with IVDU and can lead to fatal complications such sepsis, septic emboli, and death. 22 , 23 Microbes within thrombi may produce gas, corroborated by past literature. 24 Given the many possible complications of STP, early diagnosis and prompt treatment is essential to reduce mortality and morbidity. In this report, we present a unique case of DVT with intraluminal gas complicated with rare polymicrobial R. mucilaginosa fungemia and P. intermedia bacteremia in a patient with IVDU and no known immunodeficiency. Case Description A 31-year-old afebrile male with a past medical history of untreated hepatitis C, tobacco and intravenous fentanyl use presented to the emergency department (ED) with one-week history of increased clear, malodorous drainage and pain worsening with movement from a chronic right groin injection site wound that had been present for over a year. He also complained of associated subjective fevers, nausea, and vomiting over the past week. The patient stated he occasionally licked the needle prior to injection of the site. He reported mild improvement of symptoms after receiving an IM dose of antibiotics at urgent care before arriving to the ED. The patient otherwise denied headache, visual changes, CP, dyspnea, abdominal pain, back pain, dysuria, blood in urine or stool, and rash. He also denied history of groin infection, infective endocarditis, or bacteremia. On physical exam, the patient had a small skin defect in the right groin with the appearance of a one-centimeter laceration or sinus tract. The area had no surrounding erythema, increased tenderness, active draining, fluctuance, induration, and crepitus at the time of exam. A timeline of these events is shown in Fig. 1 . A bedside ultrasound in the ED was performed to evaluate for abscess given the history of prurient drainage from wound. The ultrasound, shown in Fig. 2 , revealed a large right common femoral DVT extending into the iliac vein system, with hyperechoic material within the thrombus concerning for intraluminal gas. A computed tomography (CT) with IV contrast of the abdomen and pelvis, shown in Fig. 3 , confirmed the presence of intraluminal gas within a thrombus extending into the external iliac vein alongside a superimposed infection. The intraluminal gas extended from the common femoral vein to the external iliac vein. A urine drug screen was positive for fentanyl and amphetamines. Hematologic testing at admission showed normocytic anemia and elevated inflammatory markers but no significant derangement of serum electrolytes. White blood cell counts were only slightly abnormal, limited to mild elevations in neutrophil count and reduced lymphocyte count. A summary of these values is shown in Supplemental Table S1 . An HIV screen was negative, and blood was taken for culture. The patient was admitted to inpatient medicine service and promptly started on antibiotics including one time IV dosage of piperacillin/tazobactam, a five-day course of IV cefepime (two grams in 20 mL 0.9% sodium chloride), oral metronidazole (500mg), and a seven-day course of vancomycin (one gram in 200 mL 0.9% sodium chloride every eight hours) due to high suspicion of septic thrombophlebitis. Vascular surgery was consulted, with heparin drip initiated for anticoagulation due to the DVT. Blood cultures obtained at time of ED admission grew gram-positive cocci (GPC) in clusters, gram-negative rods, Prevotella intermedia , and budding yeast consistent with Rhodotorula mucilaginosa fungemia. After consulting with infectious disease physicians, cefepime was discontinued and replaced with IV ampicillin/sulbactam (three grams in 100 mL 0.9% sodium chloride every six hours) to cover P. intermedia , Streptococcus mitis group, and the anaerobic organisms. Vancomycin was continued for coverage of GPC, and a two-day course of micafungin (100 mg in 100mL 0.9% sodium chloride once daily) was started for R. mucilaginosa . The patient underwent irrigation and debridement of the right groin wound by vascular surgery. Fibrotic tissue surrounding a mature sinus tract down to the femoral vessels but not involving the vessels was found, but there was no evidence of any purulence or fluid collections. Furthermore, there was no bleeding, defect, or pseudoaneurysm in either the femoral artery or the femoral vein. The sinus tract was completely excised and sent for culture alongside two deep tissue samples measuring 2.1 x 2.5 x 1.1 cm in aggregate. Intraoperative cultures grew mixed anaerobic flora, gram negative rods, gram positive rods, and Streptococcus mitis . Transesophageal echocardiogram (TEE) was recommended due to the fungemia, bacteremia, and multiple risk factors for infective endocarditis (IE); TEE showed a small, 0.5 cm, filamentous, highly mobile mass on the atrial aspect of the anterior leaflet of mitral valve concerning for endocarditis. No definite vegetation was identified, and upon further consult with infectious disease physicians the mass was determined unlikely to be associated with infectious endocarditis. The patient remained afebrile and hemodynamically stable. Given the positivity of blood cultures and prior IVDU but uncertain etiology of the cardiac mass, Duke Criteria was met only for possible endocarditis. The patient underwent a venogram which revealed a chronic right iliac and femoral vein DVT which vascular surgery was able to recanalize with thrombectomy. Operative cultures from the thrombus were negative. The patient made a full recovery and was discharged with a four-week course of oral amoxicillin/clavulanic acid (875 − 125 mg every twelve hours) and oral voriconazole (250 mg every twelve hours). He was also started on therapeutic anticoagulation with rivaroxaban due to the large burden of venous thrombosis. An outpatient visit with infectious disease in six weeks for surveillance of IE was scheduled and outpatient hepatology follow-up was recommended for management of the patient's untreated chronic hepatitis C infection. Discussion This case demonstrates novel and multifaceted complications associated with IVDU, including an unusual presentation of DVT with gas present in the thrombus and infection with Rhodotorula mucilaginosa despite immunocompetence of the patient. The presence of gas within the lumen of a thrombus has been previously reported in septic thrombophlebitis; to our knowledge this is the first reported case of intraluminal gas being detected via bedside ultrasound. Additionally, infection of an immunocompetent IV drug using-patient with R. mucilaginosa has not been reported previously. Importantly, the thrombus and rare polymicrobial infection was associated with a small, unassuming external wound with no erythema, drainage, abscess, or other obvious signs that would have predicted the sinus tract, DVT, or other subsequent findings. This highlights the importance of using routine point-of-care ultrasound in the ED when evaluating IVDU-associated wounds. In patients with high risk of complex infections, the threshold for ultrasound use should be low. The presence of gas in the thrombus suggests gas-producing pathogens within the thrombus. The patient's blood culture initially grew both the fungus R. mucilaginosa and the bacteria P. intermedia , neither of which are known to produce gas. However, the initial blood culture was also found to grow gram-negative rods and gram-positive cocci in clusters in addition to the two named pathogens. The pathogen responsible for the gas may have been one of these unidentified bacterial species. Staphylococcus aureus is a gram-positive cocci in clusters known to produce gas in soft-tissue infections 25 and is the leading cause of septic thrombophlebitis, responsible for over 50% of cases. 26 Notably, it commonly causes acute endocarditis in IV drug users 27 and thus may have also been responsible for the filamentous structure on the mitral valve. Although the femoral thrombus cultured after the thrombectomy showed no bacterial or fungal growth, the culture was performed following five days of intravenous antifungal and antibiotic therapy. Additionally, the patient had received intramuscular antibiotics at an urgent care facility before arriving at the ED. Therefore, the absence of bacterial and fungal growth in the thrombus culture could be attributed to the extensive prior antibiotic and antifungal treatment. Importantly, other signs of infection were present such as subjective fevers, chills, and positive blood and soft tissue cultures. Occurrences of intraluminal thrombus gas may thus be a strong indicator of infection and should increase suspicion of STP. Another possibility is the inadvertent introduction of air into the thrombus during the patient’s IV drug use. The polymicrobial nature of the infection, involving P. intermedia and R. mucilaginosa , adds another layer of complexity. P. intermedia , commonly associated with periodontal disease, rarely causes systemic infections but can be introduced into the bloodstream through poor injection practices such as the patient’s reported needle licking. The only reported literature of blood infection with P. intermedia in IVDU has been with polymicrobial infection. 28 Thus, blood cultures positive for P. intermedia should raise suspicion of other pathogens being present in the blood as well. The emergence of R. mucilaginosa fungemia in this patient is particularly noteworthy due to its high resistance profile and the rarity of such infections in immunocompetent individuals. 29 To our knowledge, this is the first reported case of infection with R. mucilaginosa associated with IV drug use; however, R. mucilaginosa is documented to occur with catheter-associated infections. The co-occurrence of these pathogens in the bloodstream underscores the need for thorough microbiological evaluation and targeted antimicrobial therapy in cases of thrombosis in IVDU. R. mucilaginosa should be considered as a potential pathogen in future cases of immunocompetent IVDU infections and greater attention should be paid to this increasingly prevalent 30 pathogen. Conclusion This case contains multiple novel findings with important implications for the care of patients with IVDU. First, it emphasizes the utility of point of care ultrasound when evaluating IVDU wounds. Given the lack of erythema, drainage, or abscess, this case demonstrates the need to lower the threshold for using point-of-care ultrasound in patients with risk for more complex infections. The gas present in the patient’s thrombus, the second such case of gas in thrombus concurrent with an infection reported in the literature, suggests a rare yet highly sensitive sign of septic thrombophlebitis. In cases with systemic signs of infection, a gas-enclosing thrombus may further increase the index of clinical suspicion for infection. Gas in the thrombus may also help determine the pathogens present in an infection in cases of ambiguity or multiple pathogens. Additionally, this case adds to the literature of polymicrobial infections occurring in the setting of P. intermedia infection of IV drug users. This case confirms the importance of screening for other pathogens when this pathogen is detected. Finally, this case represents the first reported case of R. mucilaginosa in an immunocompetent IV drug user, demonstrating that infection with this species does not always occur in the context of immunosuppression. R. mucilaginosa , though still rare, is an emerging pathogen and should be considered as a possibility when assessing infections in IV drug users. Declarations Ethics approval and consent to participate: Not applicable. Clinical Trial: Not applicable. Consent for publication : The patient was contacted after his hospital admission and shown the entire manuscript, including photos, before giving written consent for publication. Availability of data and material : Imaging data is provided within supplementary data files. Competing interests : The authors declare no competing interests. Funding: Not applicable. Authors' contributions: The patient was original seen and treated in the emergency department by S.N. Manuscript was written by N.S. and S.C. 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Clin Imaging. 1998;22(2):122–3. 10.1016/s0899-7071(97)00077-6 . Saliba WR, Goldstein LH, Raz R, Mader R, Colodner R, Elias MS. Subacute necrotizing fasciitis caused by gas-producing Staphylococcus aureus. Eur J Clin Microbiol Infect Dis. 2003;22(10):612–4. 10.1007/s10096-003-1023-2 . Kaufman JA. CHAPTER 16 - Lower-extremity Veins. In: Kaufman JA, Lee MJ, editors. Vascular and Interventional Radiology . The Requisites. W.B. Saunders; 2004. pp. 445–68. 10.1016/B978-0-8151-4369-7.50024-X . Murdoch DR, Corey GR, Hoen B, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med. 2009;169(5):463–73. 10.1001/archinternmed.2008.603 . Wang’ondu RW, Murray TS. Relapse of Polymicrobial Endocarditis in an Intravenous Drug User. Yale J Biol Med. 2011;84(3):321–4. Spiliopoulou A, Anastassiou ED, Christofidou M. Rhodotorula fungemia of an intensive care unit patient and review of published cases. Mycopathologia. 2012;174(4):301–9. 10.1007/s11046-012-9552-9 . Miceli MH, Díaz JA, Lee SA. Emerging opportunistic yeast infections. Lancet Infect Dis. 2011;11(2):142–51. 10.1016/S1473-3099(10)70218-8 . Additional Declarations No competing interests reported. Supplementary Files S1forDVTCaseStudy.docx Rightgroinultrasound.mp4 SagittalExternalIlliac.jpeg SagittalCommonFemoral.jpeg CoronalExternalIlliac.jpeg CoronalCommonFemoral.jpeg AxialExternalIlliac.jpeg AxialCommonFemoral.jpeg Cite Share Download PDF Status: Published Journal Publication published 29 Sep, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 28 Apr, 2025 Reviewers agreed at journal 28 Apr, 2025 Reviewers agreed at journal 28 Apr, 2025 Reviewers agreed at journal 28 Apr, 2025 Reviewers agreed at journal 28 Apr, 2025 Reviews received at journal 28 Apr, 2025 Reviewers agreed at journal 28 Apr, 2025 Reviewers agreed at journal 27 Apr, 2025 Reviewers agreed at journal 26 Apr, 2025 Reviewers agreed at journal 26 Apr, 2025 Reviewers agreed at journal 26 Apr, 2025 Reviewers agreed at journal 25 Apr, 2025 Reviewers agreed at journal 25 Apr, 2025 Reviews received at journal 25 Apr, 2025 Reviews received at journal 24 Apr, 2025 Reviewers agreed at journal 24 Apr, 2025 Reviewers agreed at journal 24 Apr, 2025 Reviewers agreed at journal 24 Apr, 2025 Reviewers agreed at journal 24 Apr, 2025 Reviewers agreed at journal 24 Apr, 2025 Reviews received at journal 24 Apr, 2025 Reviews received at journal 24 Apr, 2025 Reviewers agreed at journal 24 Apr, 2025 Reviewers agreed at journal 23 Apr, 2025 Reviewers agreed at journal 23 Apr, 2025 Reviewers agreed at journal 23 Apr, 2025 Reviewers agreed at journal 23 Apr, 2025 Reviewers agreed at journal 23 Apr, 2025 Reviewers agreed at journal 23 Apr, 2025 Reviewers invited by journal 14 Apr, 2025 Submission checks completed at journal 14 Apr, 2025 First submitted to journal 10 Apr, 2025 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. 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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-5545236","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":442866638,"identity":"e0b10175-faaa-4408-bb0e-540cbd34d9f3","order_by":0,"name":"Nima Shariatzadeh","email":"data:image/png;base64,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","orcid":"","institution":"The University of Texas Health Science Center at San Antonio","correspondingAuthor":true,"prefix":"","firstName":"Nima","middleName":"","lastName":"Shariatzadeh","suffix":""},{"id":442866641,"identity":"618dd878-a92b-4923-804d-eef6dd46b39d","order_by":1,"name":"Suchit Chidurala","email":"","orcid":"","institution":"The University of Texas Health Science Center at San Antonio","correspondingAuthor":false,"prefix":"","firstName":"Suchit","middleName":"","lastName":"Chidurala","suffix":""},{"id":442866644,"identity":"3278da94-324d-4209-90c8-dc341dc934d4","order_by":2,"name":"Samuel Nesemann","email":"","orcid":"","institution":"The University of Texas Health Science Center at San Antonio","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"","lastName":"Nesemann","suffix":""}],"badges":[],"createdAt":"2024-11-29 00:08:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5545236/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5545236/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-025-11180-2","type":"published","date":"2025-09-29T15:58:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80784306,"identity":"72cd3a63-d1bd-4db6-be89-df0e070031ad","added_by":"auto","created_at":"2025-04-17 05:34:56","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":115464,"visible":true,"origin":"","legend":"\u003cp\u003eTimeline of events prior to patient presenting at the emergency department (ED)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5545236/v1/f8ecbe3f1ca3e7e4fceee966.jpeg"},{"id":80784312,"identity":"dd5307b7-df16-4145-bd81-fbc7af2de911","added_by":"auto","created_at":"2025-04-17 05:34:56","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":151683,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasound of the right groin using a linear probe shows the common femoral vein with hyperechoic material indicating a DVT. The areas outlined in red show areas of increased echogenicity with ringdown artifact indicating gas within the DVT.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5545236/v1/38823380a625c9e211485870.jpeg"},{"id":80785776,"identity":"9481f83b-7c8b-4e9d-b253-e4361a6d1160","added_by":"auto","created_at":"2025-04-17 05:42:57","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":544283,"visible":true,"origin":"","legend":"\u003cp\u003eA CT with IV contrast scan of the abdomen and pelvis with intraluminal air circled in red shown in the A. Coronal view with air in the common femoral vein, B. Axial view with air in the common femoral vein, C. Sagittal view with air in the common femoral vein, D. Coronal view with air in the external iliac vein, E. Coronal view with air in the external iliac vein, F. Sagittal view with air in the external iliac vein. Figure created using Biorender.com.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5545236/v1/23905017bb203a239520667d.jpeg"},{"id":92885115,"identity":"554d6a86-5c3f-4496-a65c-40572b04f576","added_by":"auto","created_at":"2025-10-06 16:14:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1282235,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5545236/v1/c2b194f6-8c5f-49f5-81e1-7152c113b8e9.pdf"},{"id":80784307,"identity":"0ebaf4d3-afad-476f-b7f2-f8a3fda60cf3","added_by":"auto","created_at":"2025-04-17 05:34:56","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20457,"visible":true,"origin":"","legend":"","description":"","filename":"S1forDVTCaseStudy.docx","url":"https://assets-eu.researchsquare.com/files/rs-5545236/v1/67ae62fa7686fbd495482e40.docx"},{"id":80785777,"identity":"f1608350-e30d-492d-ac6d-8db0a1634779","added_by":"auto","created_at":"2025-04-17 05:42:57","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":5901080,"visible":true,"origin":"","legend":"","description":"","filename":"Rightgroinultrasound.mp4","url":"https://assets-eu.researchsquare.com/files/rs-5545236/v1/2f8a6c8ab014812bde952ee1.mp4"},{"id":80784310,"identity":"4c510d67-8f6e-433b-8284-130a80552c18","added_by":"auto","created_at":"2025-04-17 05:34:56","extension":"jpeg","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":179360,"visible":true,"origin":"","legend":"","description":"","filename":"SagittalExternalIlliac.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5545236/v1/fbd42d86f1572b650ceb6769.jpeg"},{"id":80784317,"identity":"bbe2f969-8adc-4337-9440-530147127550","added_by":"auto","created_at":"2025-04-17 05:34:57","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":173854,"visible":true,"origin":"","legend":"","description":"","filename":"SagittalCommonFemoral.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5545236/v1/e2b791f855817bb228248681.jpeg"},{"id":80784315,"identity":"3edbd9b1-ffbc-4aea-a519-f0af536d28a3","added_by":"auto","created_at":"2025-04-17 05:34:57","extension":"jpeg","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":253218,"visible":true,"origin":"","legend":"","description":"","filename":"CoronalExternalIlliac.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5545236/v1/0565c8060b77bd2b27e82aff.jpeg"},{"id":80784322,"identity":"28b8be34-bfc5-4c1e-a781-ec5139589e5c","added_by":"auto","created_at":"2025-04-17 05:34:57","extension":"jpeg","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":220320,"visible":true,"origin":"","legend":"","description":"","filename":"CoronalCommonFemoral.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5545236/v1/882690ab49793f444d5458c4.jpeg"},{"id":80784309,"identity":"1b94048a-4b0c-47ed-bd70-5b666ba7d3ce","added_by":"auto","created_at":"2025-04-17 05:34:56","extension":"jpeg","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":40221,"visible":true,"origin":"","legend":"","description":"","filename":"AxialExternalIlliac.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5545236/v1/5041b68be2afb2476131e777.jpeg"},{"id":80784319,"identity":"4cf32338-e63e-4bc1-a58d-e2f0e5fe8c74","added_by":"auto","created_at":"2025-04-17 05:34:57","extension":"jpeg","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":40885,"visible":true,"origin":"","legend":"","description":"","filename":"AxialCommonFemoral.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5545236/v1/7ee38825853cd2b0f6567847.jpeg"}],"financialInterests":"No competing interests reported.","formattedTitle":"Intraluminal Gas in Deep Vein Thrombosis Associated with Rhodotorula mucilaginosa Fungemia and Prevotella intermedia Bacteremia: A Unique Clinical Case Report and Literature Overview","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIntravenous drug usage (IVDU) has significantly increased in the United States with about 3.5\u0026nbsp;million individuals injecting drugs.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e IVDU poses a significant health burden as it is often associated with increased mortality and morbidity. Degenhardt et al. report that 15% of people who inject drugs live with HIV, 39% have HCV infection, 18.5% have recently overdosed, and 32% have had a skin or soft tissue infection.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The most common bacterial infections associated with IVDU originate from skin, oral cavity, or environment.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Oral microbiota, specifically, can cause infection in IVDU as poor hygiene practices like needle licking are conducted by up to one third of people injecting drugs.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e \u003cem\u003ePrevotella intermedia\u003c/em\u003e is an obligate anaerobic gram-negative bacilli that is normally found in the oral cavity and can rarely cause infection in IVDU.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e \u003cem\u003eP. intermedia\u003c/em\u003e is mostly associated with periodontal disease, and there is very little literature regarding bacteremia caused by it, especially in the case of IVDU.\u003csup\u003e\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFungal infections can also cause serious complications in IVDU.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e While mostly associated with intravenous catheter placement, \u003cem\u003eRhodotorula mucilaginosa\u003c/em\u003e is an environmental basidiomycete yeast that can colonize the skin, respiratory, and gastrointestinal tracts.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Notably, it has been found in tap water and common household appliances.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e \u003cem\u003eR. mucilaginosa\u003c/em\u003e is an emerging pathogen with high resistance profile and considerable morbidity and mortality, particularly in immunocompromised hosts.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Few cases of \u003cem\u003eR. mucilaginosa\u003c/em\u003e have been reported in immunocompetent individuals, and, to our knowledge, no case of \u003cem\u003eR. mucilaginosa\u003c/em\u003e has been reported in association with IVDU.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Given the highly resistant nature of \u003cem\u003eR. mucilaginosa\u003c/em\u003e, understanding previously successful treatments is crucial for managing this emerging pathogen.\u003c/p\u003e \u003cp\u003eIVDU can also cause deep vein thrombosis (DVT). DVT can be caused by many factors including reduced blood flow, increased venous pressure, mechanical injury to the vein by various injuries like trauma or IVDU, increased blood viscosity, and increased coagulation risk either acquired or genetic.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Szlaszynska et al. reported the prevalence of DVT in people injecting drugs was 29% while 15% of all DVT cases were associated with IVDU.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e DVT can be asymptomatic but typically presents with pain, warmth, redness, and swelling of the lower extremity with an increased incidence after 40 years of age.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e However, DVT in IVDU usually differs in presentation with a higher incidence in younger patients and poorer outcomes/complications like slower recovery, recurrent venous thromboembolism, and a longer hospital stay, all of which increase the risk of morbidity, mortality, reduced productivity, and economic burden.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e DVT can also occur in the setting of a bacterial or fungal infection, which is referred to as septic thrombophlebitis (STP). STP is associated with IVDU and can lead to fatal complications such sepsis, septic emboli, and death.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Microbes within thrombi may produce gas, corroborated by past literature.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Given the many possible complications of STP, early diagnosis and prompt treatment is essential to reduce mortality and morbidity.\u003c/p\u003e \u003cp\u003eIn this report, we present a unique case of DVT with intraluminal gas complicated with rare polymicrobial \u003cem\u003eR. mucilaginosa\u003c/em\u003e fungemia and \u003cem\u003eP. intermedia\u003c/em\u003e bacteremia in a patient with IVDU and no known immunodeficiency.\u003c/p\u003e"},{"header":"Case Description","content":"\u003cp\u003eA 31-year-old afebrile male with a past medical history of untreated hepatitis C, tobacco and intravenous fentanyl use presented to the emergency department (ED) with one-week history of increased clear, malodorous drainage and pain worsening with movement from a chronic right groin injection site wound that had been present for over a year. He also complained of associated subjective fevers, nausea, and vomiting over the past week. The patient stated he occasionally licked the needle prior to injection of the site. He reported mild improvement of symptoms after receiving an IM dose of antibiotics at urgent care before arriving to the ED. The patient otherwise denied headache, visual changes, CP, dyspnea, abdominal pain, back pain, dysuria, blood in urine or stool, and rash. He also denied history of groin infection, infective endocarditis, or bacteremia. On physical exam, the patient had a small skin defect in the right groin with the appearance of a one-centimeter laceration or sinus tract. The area had no surrounding erythema, increased tenderness, active draining, fluctuance, induration, and crepitus at the time of exam. A timeline of these events is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA bedside ultrasound in the ED was performed to evaluate for abscess given the history of prurient drainage from wound. The ultrasound, shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, revealed a large right common femoral DVT extending into the iliac vein system, with hyperechoic material within the thrombus concerning for intraluminal gas.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA computed tomography (CT) with IV contrast of the abdomen and pelvis, shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, confirmed the presence of intraluminal gas within a thrombus extending into the external iliac vein alongside a superimposed infection. The intraluminal gas extended from the common femoral vein to the external iliac vein.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA urine drug screen was positive for fentanyl and amphetamines. Hematologic testing at admission showed normocytic anemia and elevated inflammatory markers but no significant derangement of serum electrolytes. White blood cell counts were only slightly abnormal, limited to mild elevations in neutrophil count and reduced lymphocyte count. A summary of these values is shown in Supplemental Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e. An HIV screen was negative, and blood was taken for culture. The patient was admitted to inpatient medicine service and promptly started on antibiotics including one time IV dosage of piperacillin/tazobactam, a five-day course of IV cefepime (two grams in 20 mL 0.9% sodium chloride), oral metronidazole (500mg), and a seven-day course of vancomycin (one gram in 200 mL 0.9% sodium chloride every eight hours) due to high suspicion of septic thrombophlebitis. Vascular surgery was consulted, with heparin drip initiated for anticoagulation due to the DVT.\u003c/p\u003e \u003cp\u003eBlood cultures obtained at time of ED admission grew gram-positive cocci (GPC) in clusters, gram-negative rods, \u003cem\u003ePrevotella intermedia\u003c/em\u003e, and budding yeast consistent with \u003cem\u003eRhodotorula mucilaginosa\u003c/em\u003e fungemia. After consulting with infectious disease physicians, cefepime was discontinued and replaced with IV ampicillin/sulbactam (three grams in 100 mL 0.9% sodium chloride every six hours) to cover \u003cem\u003eP. intermedia\u003c/em\u003e, Streptococcus mitis group, and the anaerobic organisms. Vancomycin was continued for coverage of GPC, and a two-day course of micafungin (100 mg in 100mL 0.9% sodium chloride once daily) was started for \u003cem\u003eR. mucilaginosa\u003c/em\u003e. The patient underwent irrigation and debridement of the right groin wound by vascular surgery. Fibrotic tissue surrounding a mature sinus tract down to the femoral vessels but not involving the vessels was found, but there was no evidence of any purulence or fluid collections. Furthermore, there was no bleeding, defect, or pseudoaneurysm in either the femoral artery or the femoral vein. The sinus tract was completely excised and sent for culture alongside two deep tissue samples measuring 2.1 x 2.5 x 1.1 cm in aggregate. Intraoperative cultures grew mixed anaerobic flora, gram negative rods, gram positive rods, and \u003cem\u003eStreptococcus mitis\u003c/em\u003e. Transesophageal echocardiogram (TEE) was recommended due to the fungemia, bacteremia, and multiple risk factors for infective endocarditis (IE); TEE showed a small, 0.5 cm, filamentous, highly mobile mass on the atrial aspect of the anterior leaflet of mitral valve concerning for endocarditis. No definite vegetation was identified, and upon further consult with infectious disease physicians the mass was determined unlikely to be associated with infectious endocarditis. The patient remained afebrile and hemodynamically stable. Given the positivity of blood cultures and prior IVDU but uncertain etiology of the cardiac mass, Duke Criteria was met only for possible endocarditis.\u003c/p\u003e \u003cp\u003eThe patient underwent a venogram which revealed a chronic right iliac and femoral vein DVT which vascular surgery was able to recanalize with thrombectomy. Operative cultures from the thrombus were negative. The patient made a full recovery and was discharged with a four-week course of oral amoxicillin/clavulanic acid (875\u0026thinsp;\u0026minus;\u0026thinsp;125 mg every twelve hours) and oral voriconazole (250 mg every twelve hours). He was also started on therapeutic anticoagulation with rivaroxaban due to the large burden of venous thrombosis. An outpatient visit with infectious disease in six weeks for surveillance of IE was scheduled and outpatient hepatology follow-up was recommended for management of the patient's untreated chronic hepatitis C infection.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case demonstrates novel and multifaceted complications associated with IVDU, including an unusual presentation of DVT with gas present in the thrombus and infection with \u003cem\u003eRhodotorula mucilaginosa\u003c/em\u003e despite immunocompetence of the patient. The presence of gas within the lumen of a thrombus has been previously reported in septic thrombophlebitis; to our knowledge this is the first reported case of intraluminal gas being detected via bedside ultrasound. Additionally, infection of an immunocompetent IV drug using-patient with \u003cem\u003eR. mucilaginosa\u003c/em\u003e has not been reported previously. Importantly, the thrombus and rare polymicrobial infection was associated with a small, unassuming external wound with no erythema, drainage, abscess, or other obvious signs that would have predicted the sinus tract, DVT, or other subsequent findings. This highlights the importance of using routine point-of-care ultrasound in the ED when evaluating IVDU-associated wounds. In patients with high risk of complex infections, the threshold for ultrasound use should be low.\u003c/p\u003e \u003cp\u003eThe presence of gas in the thrombus suggests gas-producing pathogens within the thrombus. The patient's blood culture initially grew both the fungus \u003cem\u003eR. mucilaginosa\u003c/em\u003e and the bacteria \u003cem\u003eP. intermedia\u003c/em\u003e, neither of which are known to produce gas. However, the initial blood culture was also found to grow gram-negative rods and gram-positive cocci in clusters in addition to the two named pathogens. The pathogen responsible for the gas may have been one of these unidentified bacterial species. \u003cem\u003eStaphylococcus aureus\u003c/em\u003e is a gram-positive cocci in clusters known to produce gas in soft-tissue infections\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e and is the leading cause of septic thrombophlebitis, responsible for over 50% of cases.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Notably, it commonly causes acute endocarditis in IV drug users\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e and thus may have also been responsible for the filamentous structure on the mitral valve. Although the femoral thrombus cultured after the thrombectomy showed no bacterial or fungal growth, the culture was performed following five days of intravenous antifungal and antibiotic therapy. Additionally, the patient had received intramuscular antibiotics at an urgent care facility before arriving at the ED. Therefore, the absence of bacterial and fungal growth in the thrombus culture could be attributed to the extensive prior antibiotic and antifungal treatment. Importantly, other signs of infection were present such as subjective fevers, chills, and positive blood and soft tissue cultures. Occurrences of intraluminal thrombus gas may thus be a strong indicator of infection and should increase suspicion of STP. Another possibility is the inadvertent introduction of air into the thrombus during the patient\u0026rsquo;s IV drug use.\u003c/p\u003e \u003cp\u003eThe polymicrobial nature of the infection, involving \u003cem\u003eP. intermedia\u003c/em\u003e and \u003cem\u003eR. mucilaginosa\u003c/em\u003e, adds another layer of complexity. P. \u003cem\u003eintermedia\u003c/em\u003e, commonly associated with periodontal disease, rarely causes systemic infections but can be introduced into the bloodstream through poor injection practices such as the patient\u0026rsquo;s reported needle licking. The only reported literature of blood infection with \u003cem\u003eP. intermedia\u003c/em\u003e in IVDU has been with polymicrobial infection.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Thus, blood cultures positive for \u003cem\u003eP. intermedia\u003c/em\u003e should raise suspicion of other pathogens being present in the blood as well. The emergence of \u003cem\u003eR. mucilaginosa\u003c/em\u003e fungemia in this patient is particularly noteworthy due to its high resistance profile and the rarity of such infections in immunocompetent individuals.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e To our knowledge, this is the first reported case of infection with \u003cem\u003eR. mucilaginosa\u003c/em\u003e associated with IV drug use; however, \u003cem\u003eR. mucilaginosa\u003c/em\u003e is documented to occur with catheter-associated infections. The co-occurrence of these pathogens in the bloodstream underscores the need for thorough microbiological evaluation and targeted antimicrobial therapy in cases of thrombosis in IVDU. \u003cem\u003eR. mucilaginosa\u003c/em\u003e should be considered as a potential pathogen in future cases of immunocompetent IVDU infections and greater attention should be paid to this increasingly prevalent\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e pathogen.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case contains multiple novel findings with important implications for the care of patients with IVDU. First, it emphasizes the utility of point of care ultrasound when evaluating IVDU wounds. Given the lack of erythema, drainage, or abscess, this case demonstrates the need to lower the threshold for using point-of-care ultrasound in patients with risk for more complex infections. The gas present in the patient\u0026rsquo;s thrombus, the second such case of gas in thrombus concurrent with an infection reported in the literature, suggests a rare yet highly sensitive sign of septic thrombophlebitis. In cases with systemic signs of infection, a gas-enclosing thrombus may further increase the index of clinical suspicion for infection. Gas in the thrombus may also help determine the pathogens present in an infection in cases of ambiguity or multiple pathogens. Additionally, this case adds to the literature of polymicrobial infections occurring in the setting of \u003cem\u003eP. intermedia\u003c/em\u003e infection of IV drug users. This case confirms the importance of screening for other pathogens when this pathogen is detected. Finally, this case represents the first reported case of \u003cem\u003eR. mucilaginosa\u003c/em\u003e in an immunocompetent IV drug user, demonstrating that infection with this species does not always occur in the context of immunosuppression. \u003cem\u003eR. mucilaginosa\u003c/em\u003e, though still rare, is an emerging pathogen and should be considered as a possibility when assessing infections in IV drug users.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: The patient was contacted after his hospital admission and shown the entire manuscript, including photos, before giving written consent for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e: Imaging data is provided within supplementary data files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eThe patient was original seen and treated in the emergency department by S.N. Manuscript was written by N.S. and S.C. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBradley H, Hall EW, Asher A, et al. Estimated Number of People Who Inject Drugs in the United States. Clin Infect Dis. 2022;76(1):96\u0026ndash;102. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/cid/ciac543\u003c/span\u003e\u003cspan address=\"10.1093/cid/ciac543\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDegenhardt L, Webb P, Colledge-Frisby S, et al. Epidemiology of injecting drug use, prevalence of injecting-related harm, and exposure to behavioural and environmental risks among people who inject drugs: a systematic review. 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Lancet Infect Dis. 2011;11(2):142\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S1473-3099(10)70218-8\u003c/span\u003e\u003cspan address=\"10.1016/S1473-3099(10)70218-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"septic thrombophlebitis, case report, IV drug use, Rhodotorula mucilaginosa, intraluminal gas","lastPublishedDoi":"10.21203/rs.3.rs-5545236/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5545236/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntravenous drug use (IVDU) is associated with multiple complications, including thrombus and infection with rare pathogens. Here, we present a unique case of septic thrombophlebitis with gas present within the lumen of the thrombus that was identified from an otherwise unassuming wound in a point-of-care ultrasound. In conjunction with past literature, this finding supports the presence of intraluminal gas as a strong indicator of septic thrombophlebitis. Furthermore, the patient\u0026rsquo;s polymicrobial infection with \u003cem\u003eRhodotorula mucilaginosa\u003c/em\u003e and \u003cem\u003ePrevotella intermedia\u003c/em\u003e expands the types of pathogens that should be suspected in IVDU-related infections. This case is the first reported infection of an immunocompetent IVDU patient with \u003cem\u003eRhodotorula mucilaginosa.\u003c/em\u003e Though rare, greater attention should be paid to this emerging pathogen in IVDU. This case highlights the importance of a low threshold for using a point-of-care ultrasound in patients with IVDU or other risk factors for complex infections.\u003c/p\u003e","manuscriptTitle":"Intraluminal Gas in Deep Vein Thrombosis Associated with Rhodotorula mucilaginosa Fungemia and Prevotella intermedia Bacteremia: A Unique Clinical Case Report and Literature Overview","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-17 05:34:51","doi":"10.21203/rs.3.rs-5545236/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision 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