Facial vein thrombophlebitis is extremely rare in the current antibiotic era. There is only one case report described in the English lanuage literature of a patient with this condition secondary to a sore on her upper lip which acted as a portal of entry for the infection. The French and Russian literature have several case reports and case series dating back to the 60’s described as complications of furuncles and carbuncles.
A 39-year-old woman was bought to the emergency department with dyspnea, chest and back pain, along with tenderness, erythema and swelling on the right side of her face. Her symptoms began 2 weeks ago, with a painful vesicular rash involving the lower right side of her face around the lips. She was diagnosed with herpes zoster and started on oral acyclovir therapy. After approximately 10 days she noticed increased swelling, erythema and tenderness at the angle of the jaw on the right spreading along her right cheek. This was followed a day later by increased shortness of breath, chest and back pain. The patient moved from Pakistan 9 years ago. She had a history of hypothyroidism on levothyroxine replacement, which was her only daily medication. She had no allergies and worked as a housewife. Physical Examination revealed a middle aged female in moderate distress. On admission her temperature was 39.1°C, heart rate was 119 beats/min, BP was 148/78 mm Hg, respiratory rate was 28 per min, and oxygen saturation was 93% on room air. Focused physical exam revealed a vesicular rash around the right side of the lips, and swelling, redness and warmth over her right cheek. Cranial nerve examination was normal. Chest auscultation and percussion were normal. Cardiac exam revealed tachycardia without murmurs. Laboratory evaluation revealed normal electrolyte and hepatic panel. The WBC count was 14.9 with a left shift. Hemoglobin and platelet counts were normal. Plain chest film shows bilateral nodular densities. CT scan of the thorax revealed multiple pulmonary nodules bilaterally, some of which were cavitary, wedge-shaped and peripheral in distribution. CT scan of the neck showed complete occlusion of the right anterior facial vein without extension into the jugular vein proper. There was surrounding edema and induration without frank abscess formation or lymphadenopathy. Patient was started on broad-spectrum antibiotics. Transthoracic echocardiogram did not show valvular vegetations. Blood cultures grew staphylococcus aureus (MRSA) sensitive to vancomycin, bactrim and clindamycin consistent with a community acquired MRSA sensitivity profile. Patient was continued on vancomycin for the next 4 weeks with significant clinical improvement. A repeat CT scan of the thorax 5 months later showed almost complete resolution of the nodular lung densities.
The anterior facial vein starts just below the medial epicanthal fold bilaterally as a continuation of the angular vein. It connects with the cavernous sinus proximally and the jugular vein distally. Intection in this area if left untreated, could lead to devastating complications like cavernous sinus thrombosis. Septic embolic complication to any organ is also possible. Our patient had septic pulmonary emboli which resolved completely with antibiotic therapy. Duration of antibiotic therapy ranges from 2–6 weeks in different case reports.
Thrombophlebitis of the anterior facial vein is rare and therefore a high index of suspicion is needed to diagnose and treat the disease early and aggressively to avoid potentially fatal complications. Most common organim is Staphylococcus Aureus and portal of entry is generally an area of damaged skin overlying the vein.
Ali Kanchwala, No Financial Disclosure Information; No Product/Research Disclosure Information