Management of Candidal Thrombophlebitis of the Central Veins: Case Report and Review

Abstract

Candidemia and major organ candidiasis are problems that emerged in the past 2 decades and that are partially due to medical progress. Catheter-related thrombosis of the central veins is known to be a frequent but mostly subclinical complication of central venous lines. Although candidemia and catheter-related thrombosis are frequent, candida thrombophlebitis of the central veins is rarely reported. We recently successfully treated a 19-year-old polytrauma patient with candidal thrombophlebitis of the innominate vein. Despite catheter removal and therapy with amphotericin B, recurrent candidemia and signs of infection persisted, and a complete resection of the involved vein had to be performed. Only 16 well-documented cases of candidal thrombophlebitis of the central veins in adults have been reported over the past 20 years. An analysis of these 16 patients, together with our patient, is made in relation to risk factors, clinical features, diagnosis, therapy, and mortality.

Successful Treatment of Recurrent Candidemia due to Candidal Thrombophlebitis Associated with a Central Venous Catheter Using a Combination of Fosfluconazole and Micafungin

“…The effectiveness of combination therapy against CTCVC has been reported previously; however, these cases involved combinations of amphotericin-B and 5-fluorocytosine (8). To the extent of our knowledge, this is the first report of CTCVC being successfully treated with combination therapy including F-FLCZ and MCFG.…”

“…Therefore, high risk patients should be screened for CTCVC in the early phase of the clinical course. An echo-Doppler examination of all previously catheterized central veins or systemic CECT are highly recommended for long-term hospitalized patients with a fever of unknown origin, in order to detect a possible thrombus that is not clinically apparent (8,11). Since the clinical picture of the patient in the present case displayed the characteristics for CTCVC (critically ill surgical patient, intraabdominal infection and long-duration antibiotics treatment), the definitive diagnosis should have been made earlier.…”

“…Instead, a persistent fever during or after the use of broad-spectrum antibiotics, recurrent detections of candidemia despite the use of antifungal agents and edema of the affected limb are considered to be the prominent clinical features of CTCVC (8). Epidemiologically, CTCVC is very rare, so the clinical suspicion tends to be delayed, which likely contributes to the mortality rate of approximately 20% (8)(9)(10). Therefore, high risk patients should be screened for CTCVC in the early phase of the clinical course.…”

“…Some reports indicate that surgical thrombectomy should be considered as a therapeutic option (15,16), but others do not (8). Medical therapy alone may be effective in some cases and surgery is not always possible because of the inaccessibility of the central veins (17)(18)(19)(20).…”

Surgical Treatment of Central Venous Catheter Related Septic Deep Venous Thrombosis

“…Unfortunately, this usually only occurs after fungemia, shock, or organ failure is recognized. 19,20 Surgical patients, especially those with intra-abdominal infection, who are critically ill while being treated with long-term antimicrobial therapy should be suspected of fungal infection. 3 The catheter should be removed in cases of central venous catheter related septic thrombosis due to Candida species.…”