Case Presentation: A 66-year-old male with history of Diabetes Mellitus Type 2, benign prostatic hyperplasia status-post transurethral resection of the prostate, anxiety, rhinorrhea with recent nasal endoscopy, and chronic natural killer lymphocytosis (NKL) who presented with three days of fever, chills, body aches, joint pain, headaches, and myalgias. On admission patient had fever, tachycardia, hypotension, mild leukocytosis, and transaminitis. Initial chest x-ray was negative for acute infiltrate and Flu/ RSV negative. He was started on supportive care and appeared to be responding well. One of two admission blood cultures grew Streptococcus anginosus and Gemella morbillorum. His hospital course was complicated with recurrent fevers and was started on metronidazole and ceftriaxone. CT sinus and chest was negative for a source but CT Abdomen/Pelvis revealed thrombosed splenic and inferior mesenteric veins with perivenous inflammation but no obvious infectious source. Transthoracic Echo was negative for vegetations. He was started on heparin for the thromboses. He clinically improved and was discharged with metronidazole, ceftriaxone, and warfarin with outpatient follow-up.
Discussion: The main pathophysiology of venous thrombosis follows Virchow’s triad of stagnant blood flow, endovascular injury, and hypercoagulable state. The inferior mesenteric vein is an uncommon site of MVT, composing up to 11% of MVT cases [1-3]. Common risk factors for developing MVT include inflammatory conditions such as bacteremia as seen in our case. Interestingly enough, this is also a risk factor for septic thrombophlebitis. In a study of 95 cases of portal thrombophlebitis, the most common site of inflammation was the right portal vein at 33% and the least common was the inferior mesenteric vein at 8% [4]. This same study found Streptococcus anginosus bacteremia was present in 8% of cases while 24% had polymicrobial infection [4]. Intriguingly, our patient presented with both during his workup for unexplained fever. CT Abdomen/Pelvis was used to diagnose both MVT and thrombophlebitis. Upon diagnosis, MVT and septic thrombophlebitis can be treated with anticoagulation and antibiotics, respectively. We encourage further review into septic thrombophlebitis and MVT to promote early detection and prevent mortality from complications such as acute mesenteric ischemia.
Conclusions: Mesenteric Vein Thrombosis is a rare condition that may cause abdominal pain but can also be found incidentally without symptoms. Bacteremia can lead to inflammatory changes responsible for developing MVTs as well as thrombophlebitis. We present an interesting cause of an inferior MVT and thrombophlebitis in a patient with bacteremia secondary to Streptococcus anginosus and Gemella morbillorum. We believe it is important to diagnose and treat mesenteric thrombosis and thrombophlebitis to prevent further complications. We hope this case brings further awareness of the disease presentation and management.