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Superficial thrombophlebitis is often thought of as a benign self-limiting disorder, warranting only symptomatic treatment with non-steroidal anti-inflammatory drugs. Lately, however, several reports have suggested an association with deep-vein thrombosis, with one study finding an unexpectedly high rate of pulmonary embolism in patients with saphenous vein thrombosis and no obvious deep-vein involvement1.
A student aged 23 was seen with a five-day history of left calf swelling which began after 6 hours of immobility at her computer. She gave no relevant medical history apart from the fact that she was awaiting varicose vein surgery. She was a non-smoker with a moderate alcohol intake (ten to twelve units per week) and had been on the combined oral contraceptive pill for the past 2 years for painful irregular periods. There was no history of recent travel. On further questioning she mentioned that her mother had had a deepvein thrombosis post partum. The patient had not experienced haemoptysis, chest pain or shortness of breath and the findings on physical examination, electrocardiography and chest radiography were unremarkable. She was afebrile and normotensive with a slightly raised D-dimer level of 0.4 mg/L (normal 0.0-0.3). The left calf had a 2 cm greater circumference than the right and a thrombosis was palpable in the short saphenous vein with mild surrounding erythema and tenderness. An ultrasound scan of her left leg confirmed the presence of thrombus in the short saphenous vein but no thrombosis was seen in the deep venous system. She was discharged on non-steroidal anti-inflammatory medication, having been given a contact telephone number in case symptoms worsened.
Six days later the patient was admitted after a collapse at home and subsequent episodes of hyperventilation. She had been out dancing the previous night and had consumed about eight units of alcohol. For the past two days she had been increasingly short of breath, with pleuritic pain around the left shoulder but no haemoptysis, sputum production or cough. On systemic examination the only obvious abnormality was shortness of breath at rest (respiration 26 per minute). Her left calf was still swollen though the calf measurements had not changed. Arterial blood pH was 7.46, PCO2 3.8 kPa and PO2 10.9 kPa, other values being within normal limits. D-dimer was now 2.8 mg/L and a VQ scan revealed multiple pulmonary emboli. A subsequent ultrasound scan of her left leg showed that thrombus had extended into the popliteal and lower superficial femoral veins. The patient was given tinzaparin and started on warfarin. On anticoagulation therapy she recovered without further incident. A thrombophilia screen revealed no genetic cause for her venous thromboembolism.
Acute superficial thrombophlebitis is a common vascular disease which is usually expected to run a `benign' clinical course2. Treatment includes non-steroidal anti-inflammatory drugs, other analgesia and rest. An association with deep venous thrombosis, however, has been reported, with frequencies of 12-44%3, and there have been several reports of pulmonary embolism in thrombophlebitis. In one study, 43 of 50 patients with superficial thrombophlebitis of the great saphenous vein had pulmonary emboli2. Seemingly, complications are more likely with superficial thrombophlebitis of the long saphenous vein rather than the short one4 though this is a contentious issue5. There are several reports of thrombus extending from the short saphenous vein into the deep-vein system5,6.
Should patients with superficial thrombophlebitis of the short and long saphenous veins receive anticoagulants? This might be justifiable not only as a way to limit progression to deep-vein thrombosis and the hazard of pulmonary embolism but also in terms of symptom relief.