Staphylococcus Aureus Infection and Internal Jugular Vein Thrombophlebitis

Ira Shah, Shakil Shaikh, Vijay Raut
Department of Pediatrics, B J Wadia Hospital for Children.

Address for Correspondence: Dr Shakil Shaikh, Department of Pediatrics, B J Wadia Hospital for Children, Mumbai, India. Email: drshakilsshaikh@rediffmail.com


Clinical Problem:
Case Report: A 10 month old male child was referred in view of fever, anasarca and respiratory distress. He was treated with ceftriaxone by referring hospital for 3 days. On presentation to us, he had pallor, was lethargic with heart rate of 140/minute, respiratory rate of 50/minute, had poor peripheral pulses with hypotension. He also had blackish lesion over right great toe and left facial nerve palsy. He was given intravenous fluid boluses and was shifted to intensive care unit for management of septic shock. He was ventilated for respiratory failure and required inotropic support also. Initial investigations showed thrombocytopenia and high CRP of 192 mg/l. Other blood investigations were unremarkable. He was initially started on ceftriaxone, cloxacillin and clindamycin as blood culture grew methicillin sensitive staphylococcus aureus. But fever persisted and he had two episodes of generalised tonic clonic convulsions on day 6 of antibiotics. Cerebrospinal fluid (CSF) analysis showed proteins of 144 mg/dl, 9000 cells/cmm with 98% of polymorphs. CSF culture did not grow any organism. Echocardiography showed no vegetations. HIV Elisa was negative. MRI brain was suggestive of subdural effusion in left fronto-parietal region with lacunar infarcts noted in cerebrum. There was right internal jugular vein (IJV) thrombosis extending to involve right distal sigmoid sinus and right cavernous sinus. Low molecular weight heparin was started. He became afebrile after 10 days of antibiotics. Repeat blood culture did not grow any organism. Repeat CSF after 21 days of antibiotics was normal. Antibiotics and heparin were stopped after 21 days and patient was discharged. His facial palsy and toe lesions had improved. He was subsequently lost to follow up.

What is the diagnosis and why is there thrombosis of the IJV?