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Retinal periphlebitis (RPP) is a long-known entity in patients with multiple sclerosis (MS) and has not been revisited in the context of recent developments in MS pathogenesis and heterogeneity. We present six cases of RPP in three female and three male MS patients. They all have relapsing-remitting MS and did not have or had minor ocular symptoms. It is important to perform a thorough retinal examination in patients with MS, as peripheral and sectorial lesions could be unseen. A better knowledge on the concomitant involvement of retinal veins contributes to the understanding of immunopathology, with potentially distinct autoantigenic targets. RPP might serve as a subphenotype marker that may influence treatment choices in MS. Further research is needed., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Introduction: Varicose veins (VV) negatively impact quality of life (QoL) and have risks of major complications including bleeding, ulceration and phlebitis. During the COVID-19 pandemic, the VSGBI (Vascular Society of Great Britain and Ireland) and GIRFT (Get It Right First Time) classified VVs as lowest priority for intervention., Objective: This study aims to determine harm caused and the impact on the QoL on patients waiting for their VVs procedures for more than 1 year., Methods: This was a prospective study conducted at the Norfolk and Norwich University Hospital (NNUH). Patients with VVs awaiting intervention for >1 year were included in the study. Patients with CEAP C6 disease were considered to be too high risk to be invited for treatment during the Covid-19 pandemic. Patients were sent QoL questionnaires and underwent a telephone consultation to assess harm. Both generic (EQ-VAS and EQ-5D) and disease-specific (AVVQ and CIVIQ-14) instruments were utilised. There were no control groups available for comparison., Results: 275 patients were identified (37.1% male) with median time on waiting list of 60 weeks (IQR 56-65). 19 patients (6.9%) came to major harm, including phlebitis (3.6%), bleeding (1.8%) and ulceration (1.8%). Fifty-two patients (18.9%) had minor harm, including worsening pain (12.7%) and swelling (6.2%). 6.9% reported psychological harm. Rising CEAP stage was also associated with worsening level of harm in patients with C5-6 disease ( p < 0.0001). Only 8.7% stated they would decline surgery during the pandemic. 104 QoL questionnaires were returned. Median EQ-VAS and EQ-5D was 75 (IQR: 60-85) and 0.685 (0.566-0.761), respectively. Median AVVQ score was 23.2 (14.9-31.0) and CIVIQ-14 score was 33 (21-44).ConclusionsThis study highlights the impact of delaying VVs surgery during a pandemic. A significant rate of both major and minor as well as psychological harm was reported. In addition, VVs had a significant detriment to quality of life.

Although nasal septal abscesses are uncommon, their cosmetic complications can be severe. Hence, prompt diagnosis and treatment are important. Here, we report a case of aseptic nasal septal abscess in a patient with proteinase 3-antineutrophil cytoplasmic antibody (PR3-ANCA)-positive ulcerative colitis (UC), in which phlebitis was observed and granulomatosis with polyangiitis (GPA) might co-exist. A 27-year-old female suffered from intermittent abdominal pain and diarrhea for several years. She visited our hospital complaining of worsening swelling and pain in the middle forehead and fever lasting 2 weeks. Physical examination and computed tomography revealed severe swelling of the nasal septum. The patient was diagnosed with nasal septal abscess, and incision drainage and biopsy from the bilateral nasal septum were performed, which showed severe ulcerative neutrophilic mucositis with phlebitis. Simultaneously, blood examination yielded slight positivity for PR3-ANCA. Colonoscopy, including biopsy, revealed severe inflammation without vasculitis nor granuloma, which led to the diagnosis with PR3-ANCA-positive UC. Phlebitis in the nasal mucosa and elevated PR3-ANCA suggested co-existing GPA; hence, she was treated with glucocorticoids and rituximab. Following treatment, the nasal septal abscess and digestive symptoms disappeared. She was discharged on day 25 without symptom recurrence or major nasal deformity. For the prevention of nasal deformity due to persistent inflammation, prompt administration of immunosuppressive therapy should be considered with adequate evaluations for systemic diseases, including UC and GPA.

The rate of syphilis in the United States has been increasing steadily in the past decade, but it remains an uncommon diagnosis in tissue biopsies. Most of the pathology literature on hepatic syphilis consists of older series or case reports. This study aimed to systematically characterize the histologic spectrum of hepatic syphilis in a contemporary cohort. Clinicopathologic features of 14 hepatic syphilis cases between 2012 and 2018 were analyzed to characterize the broad spectrum of histologic changes. Thirteen patients were men (age range: 19 to 59 y); 6 had known human immunodeficiency virus, 7 were men known to have sex with men, and no patient had known prior syphilis. Hepatic syphilis was the primary clinical suspicion in only 1 patient. Common symptoms included jaundice, rash, and abdominal pain. Thirteen had elevated transaminases, and 12 had elevated alkaline phosphatase. Pathologic changes were grouped into 5 histologic patterns: biliary-pattern injury (n=5), acute hepatitis (n=4), autoimmune hepatitis-like (n=1), fibroinflammatory mass-forming lesion (n=2), and no particular pattern (n=2). Nearly all showed portal and lobular lymphocytes and plasma cells; 12 had prominent histiocytes/Kupffer cells, 9 had ductular reaction, and 7 had duct inflammation. Occasional focal findings included dropout (n=7), phlebitis (n=7), and loose granulomata (n=5). Treponeme immunohistochemistry was positive in 10 and negative in 4, though treatment was given before biopsy in 3 of those 4. Thirteen patients had rapid plasma reagin testing either before or after biopsy, with 1:64 or higher titer. All patients who received treatment recovered. Hepatic syphilis is rare but likely underrecognized. It exhibits a variety of histologic appearances and therefore should be considered in several hepatic differential diagnoses, especially in men who have sex with men. Kupffer cells, granulomata, and phlebitis may suggest the diagnosis regardless of predominant histologic pattern. Negative treponeme immunohistochemical staining does not exclude the diagnosis, including in untreated patients., Competing Interests: Conflicts of Interest and Source of Funding: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Umbilical vein bacterial infections may cause liver abscesses during bacterial ascent. A single liver abscess can be surgically treated by marsupialization, but a risk of recurrence or non-healing remains. Moreover, there is no effective treatment for multiple abscesses., Case Presentation: A 17-day-old Holstein female calf exhibited reduced general condition, swelling and drainage of the umbilicus, and pressure sores in the area of the carpus, resulting in reluctance to stand up. The umbilicus showed pain at palpation; deep abdominal palpation indicated a swollen umbilical vein coursing from the umbilicus toward the liver. Ultrasonography confirmed a swollen umbilical vein with pus accumulation and multiple abscesses in the liver. Contrast-enhanced computed tomography (CT) examination confirmed that the swollen umbilical vein with fluid continued to the liver, and multiple unenhanced lesions, most likely abscesses, were confirmed in the liver. Partial hepatectomy was performed to remove as many abscesses as possible. For the resection, a vessel sealing device (LigaSureTM) was used to excise a part of the left liver lobe. As we could not remove all the abscesses in the liver during the operation, cefazolin sodium (5 mg/kg) was administered for 14 days after surgery. Post-operatively, blood accumulation was observed in the abdominal cavity, but no signs of peritonitis were found. The calf returned to the farm on day 38 after surgery. Follow-up information was obtained after 1 year, and complications were not reported., Conclusions: To our knowledge, this is the first report of partial hepatectomy using a vessel sealing device for a calf with multiple liver abscesses. This case report suggests that the combination of partial hepatectomy and long-term administration of antibacterial drugs may restore the health of calves with multiple liver abscesses.

Objective: To investigate the clinical characteristics and principle of treatment of occult mastoiditis accompanied with periphlcbitis of sigmoid sinus in pediatrics. Result: Four cases, with a short-time acute otitis media history, complained of headache / retroauricular pain, with papillary swelling, diagnosed as occult mastoiditis accompanied with periphlcbitis of sigmoid sinus according to the results of the temporal bone CT and MR. All of them had normal tympanic membrane, normal pure tone threshold, but type B tympanogram. CT scan of temporal bone showed soft tissue shadow of mastoid process, bone destruction of sigmoid sinus wall, and nuclear magnetic enhancement suggested cystic lesion behind mastoid process. With the usage of sufficient amount and anti-inflammatory antibiotics of permeable brain barrier, mastoidectomy were performed as early as possible. All the postoperative pathology showed inflammatory granulation, and no recurrence happened during the follow-up periods of 12-18 months. Conclusion: Intracranial complications in occult mastoiditis should be taken into account, with contemporary acute otitis media history, headache/retroauricular pain, and papillary swelling. Temporal bone image examination and hearing test should be done timely. Once the diagnosis was confirmed, on the basis of anti-infection treatment, the operation should be done as early as possible to to open the mastoid and improve the ventilation drainage of middle ear., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright© by the Editorial Department of Journal of Clinical Otorhinolaryngology Head and Neck Surgery.)

Purpose: Renal transplant patients with vascular rejection type acute T cell-mediated rejection (ATCMR) grade II have a poor prognosis. Vascular lesions in those cases are thought to randomly occur, thus we searched for a novel pathological marker related to vascular rejection in kidney transplantation., Methods: We determined pathological characteristics in 14 ATCMR grade II patients treated during an acute phase from 2004 to 2013. We then examined whether those findings appeared in transplant kidney biopsy specimens, except for cases of vascular rejection, in patients examined from 2010 to 2014., Results: In 9 of the 14 ATCMR grade II patients, phlebitis was accompanied by inflammatory cells that formed polypoid projections in the venous lumen and partial disappearance of vascular endothelium. Further investigation showed those inflammatory cells to be T cells and macrophages. Histological findings revealed coexisting phlebitis in 2 of 13 patients with ATCMR grade I, 3 of 24 with borderline changes, and none with normal findings. Phlebitis occurred at a significantly greater rate than the other findings in cases of vascular rejection (P < .05). However, there was no significant difference in regard to graft survival between patients with and without phlebitis (P = .1829)., Conclusion: Our results suggest severe phlebitis as a novel finding associated with the pathology of vascular rejection in patients with a renal allograft., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Papillophlebitis is an uncommon disease in clinical practice. We would like to present a case of a 29-year-old patient with atypical orbital pain and flashings, presenting relative afferent pupillary defect and already typical of the disease entity: ophthalmoscopic picture of the fundus and big blind spot in perimetry. We present a complex and interdisciplinary diagnostic process that excludes general diseases such as hypertension, diabetes, coagulation disorders and neurological causes. We leave the only identifiable abnormality and potential source in the inflammatory process of periodontal inflammation and sinus jaw changes. We also describe the process of remitting the changes and finally a favorable end result of the primarily a very disturbing clinical picture that this disease may present.

BACKGROUND The positioning of peripheral venous catheters (PVC) is an invasive procedure commonly performed in pediatrics hospital wards to obtain vascular access for the administration of fluids, medications and other intravenous (IV) therapies. Many studies exist about management of peripheral venous access in adults. On the contrary, scientific evidence on the management of this procedure in children and newborns, especially regarding the optimal duration of infusion and the possible related side effects, is still poor. To minimize the risk of phlebitis, the guidelines of the US Centers for Disease Control and Prevention suggest the replacement of the catheter every 72-96 hours in adult patients, while in pediatric patients the catheter can remain in place for the entire duration of the IV therapy, unless complications arise. CASE REPORT In the presented case, after the positioning of a PVC in a newborn, no clear signs/symptoms of phlebitis were registered before the sixth day and, despite the immediate removal of the catheter, the thrombotic process, secondary to phlebitis, was already occurring, causing serious and permanent disabling outcomes, susceptible to legal medical evaluation and financial compensation. CONCLUSIONS The knowledge of this case is particularly interesting to clinicians working in the field of neonatal care and to clinical risk management services inside hospital structures, since similar cases may be the source of requests for extremely high financial compensations due to medical liability.

We report a case of Trousseau's syndrome with cholangiocarcinoma complicated by a fatal pulmonary embolism after liver biopsy. A 69-year-old man who presented with right upper quadrant pain was found to have portal vein thrombosis and nonspecific liver hypodensities after imaging by computerized tomography. Following four days of anticoagulation, heparin was held for percutaneous liver biopsy. After the biopsy, he developed acute hepatic failure, acute kidney injury, lactic acidemia, and expired. Autopsy revealed intrahepatic cholangiocarcinoma and a pulmonary embolism. Trousseau's syndrome with cholangiocarcinoma is rarely reported and has a poor prognosis. This case highlights a fundamental challenge in the diagnosis and early management of intrahepatic cholangiocarcinoma with hypercoagulability. Diagnostic biopsy creates an imperative to reduce post-operative bleeding risk, but this conflicts with the need to reduce thrombotic risk in a hypercoagulable state. Considering the risk of withholding anticoagulation in patients with proven or suspected cholangiocarcinoma complicated by portal vein thrombosis, physicians should consider biopsy procedures with lesser bleeding risks, such as transjugular liver biopsy or plugged percutaneous liver biopsy, to minimize interruption of anticoagulation., (© 2016 Marshfield Clinic.)

A case of silent perforated diverticulitis in the ascending colon combined with pylephlebitis, resulting in complete occlusion of the portal trunk, is presented. A 75-year-old man with no relevant medical history visited our hospital complaining of a fever, which had lasted for 2 weeks. Although his laboratory data were indicative of severe inflammation, an abdominal examination and a computed tomography (CT) scan did not produce any significant findings. On the 6th day after admission, an abdominal CT scan detected a thrombus extending from the superior mesenteric vein to the portal vein, but did not show any signs of infection. However, on the 40th day after admission, an abdominal CT scan detected an embolus in the portal vein completely occluding the main portal trunk, as well as marked edematous changes indicative of inflammation, and an abscess in the ascending colon. We performed laparotomy and iliocecal resection, during which a perforation of the ascending colon derived from diverticulitis was found. We report this rare case and a review of the literature.

Background: Obliterative phlebitis is a useful pathological finding for the diagnosis of lymphoplasmacytic sclerosing pancreatitis (LPSP), or type 1 autoimmune pancreatitis. The present study evaluated histological findings of obliterative phlebitis, including the significance of adding Elastica van Gieson stain (EVG) in comparison with other pancreatic conditions., Methods: Specimens of LPSP (n = 18), chronic pancreatitis (CP; n = 24), and pancreatic ductal adenocarcinoma (PDA; n = 45) were enrolled. Obliterative venous lesions (OVLs), defined as the presence of inflammatory cells and/or fibrosis inside the tunica adventitia, were counted and compared between hematoxylin and eosin stain (H&E) and EVG. OVLs were classified into three types: OVL-1, lymphoplasmacytic infiltration and fibrosis against a loose textured background; OVL-2, dense fibrosis with minimal or no lymphoplasmacytic infiltration; and OVL-3, densely packed lymphoplasmacytic infiltration without fibrosis. OVL type and OVL size were compared between disease groups., Results: OVL counts in LPSP, CP, and PDA were significantly higher with EVG than with H&E (p < 0.001). OVL-1 was most common in LPSP (H&E 92.4 %, EVG 79.8 %), and was identified in almost all cases of LPSP, but was less common in CP and PDA. Maximum diameter and OVL count in 1 cm(2) of OVL-1 were high for LPSP. Maximum diameter of OVL-1 ≥150 μm was observed in 17 LPSP, 0 CP, and 1 PDA cases (sensitivity 94.4 %, specificity 98.6 %)., Conclusions: Additional EVG is useful for excluding conditions mimicking OVL-1 or detecting OVL in small specimens. The presence of OVL-1 with diameter ≥150 μm is highly diagnostic for LPSP.

We experienced severe asthmatic crisis during general anesthesia in a 45-year-old man with IgG4-related disease, COPD and athma undergoing removal of submandibular gland. The ventilatiory failure was caused by the stimulation of the operation, sputum, and neostigmine. His serum IgG4 level was extremely high. IgG4 related disease is a recently emerging entity characterized by a diffuse or mass forming inflammatory reaction rich in IgG4-positive plasma cells associated with fibrosclerosis and obliterative phlebitis. It is associated with an elevated serum level of IgG4 and an allergic disease. We must be careful in perioperative management of the patients with IgG4-related disease because general anesthesia can induce asthmatic crisis.

Thrombophlebitis of the portal venous system (PVS) with superimposed bacterial infection (septic pylephlebitis) is an extremely rare complication of Crohn's disease (CD), and therefore diagnosis of septic pylephlebitis is difficult without high clinical suspicion. A 16-year old male patient who was diagnosed with CD 3 months earlier was admitted with recurrent fever and abdominal pain. CD activity had been well controlled with conventional medical treatment during a follow-up period. Abdominal contrast-enhanced computed tomography showed massive thrombosis in the PVS without evidence of intra-abdominal infection, and blood cultures were positive for Streptococcus viridians. There was no evidence of deep vein thrombosis or pulmonary thromboembolism, and all laboratory tests for thrombophilia were normal. Based on these findings, the patient was diagnosed with septic pylephlebitis complicated with CD, and was successfully treated with intravenous antibiotic therapy combined with anticoagulation. This case suggests that early comprehensive evaluation is crucial for immediate diagnosis and proper treatment of septic pylephlebitis in patients with CD who present with fever and abdominal pain of unknown origin, even with stable disease activity and absence of other intra-abdominal infections.

Aim: The aim of this study was to evaluate if patients with Behcet's disease who have ocular involvement have a more severe form of this disease as compared to patients with Behcet's disease alone., Methods: A total of 99 patients were included in the study. 76 patients were used as part of the examined group, and 23 patients formed a control group., Results: The following are the results of examined and control groups, respectively: recurrent oral aphthous ulcers 89.5%, 95.7%; genital ulcers 61.8%, 97.0%; articular involvement 72.4%, 65.2%; vasculitis 81.6%, 60.9%; positive pathergy test 25.0%, 47.8%. Higher frequency of genital ulcerations was noted in control group (P = 0.001). More than two major criteria were met in 100% of the cases. HLA B51 was present in 78.9% of the cases in the examined group and 43.5% of the cases in control group; thus there is significant difference between them (P = 0.001). Visual acuity >0.5 occurred in 76% (examined group). Most frequent ocular manifestations in the examined group were retinal periphlebitis 81.6%, periphlebitis and periarteritis 65%, and serofibrinous uveitis 63.2%. Macular edema as a complication was present in 63.2%. The majority of patients (55.3%) were treated with combined therapy consisting of cyclosporine A and systemic corticosteroids. In 38.2% of patients, laser photocoagulation was used on retinal periphery.

Objective: To describe the etiology, symptoms and management of portal vein thrombosis associated with biliary tract infection and to compare our findings with classical causes of pylephlebitis., Material and Methods: We performed a retrospective descriptive study of 10 patients in a tertiary hospital., Results: Portal vein thrombosis was associated with biliary tract infection in seven patients and with classical causes of pylephlebitis in three. In both groups, symptoms consisted of fever and abdominal pain accompanied by leukocytosis and increased liver enzymes. Blood cultures were positive in most patients and the main complication was liver abscess. The therapeutic management and outcomes were similar in both groups., Conclusions: Portal vein thrombosis can be associated with biliary tract infection. Clinical presentation and outcomes are highly similar to those in classical causes of pylephlebitis., (Copyright © 2012 Elsevier España, S.L. and AEEH y AEG. All rights reserved.)

An 83-year-old woman presented to us with a 4-week history of general malaise, subjective fever and lower abdominal pain. Despite the intravenous infusion of antibiotics, her blood results and physical condition worsened, resulting in her sudden death. Autopsy study revealed that the medium-sized veins of the mesentery were infiltrated by eosinophil granulocytes, lymphocytes, macrophages and multinucleated giant cells; however, the arteries were not involved. Microscopically, venous giant cell infiltration was observed in the gastrointestinal tract, bladder, retroperitoneal tissues and myocardium. The final diagnosis was giant cell phlebitis, a rare disease of unknown aetiology. This case demonstrates for the first time that giant cell phlebitis involving extra-abdominal organs, including hearts, can cause serious morbidity.

The study was aimed at determining the dynamics of saphenous veins in patients with varicophlebitis of the great saphenous vein (GSV) in a subacute period (during compression therapy) and at assessing efficacy of 4-month medicamentous protection thereof. We examined a total of 32 patients presenting with the first episode of non-embolic varicophlebitis of the great saphenous vein. The comparison group comprised 16 patients undergoing 4-month compression (degree 2) therapy alone, and the study group patients (n = 16) were subjected to compression therapy combined with a 4-month course of micronized diosmin (1 tablet twice a day). The patients were included into the groups alternately as they attended our medical facility. Duplex scanning before and after the treatment course was used to measure the following parameters: 1) the evening diameter of veins and 2) an increase in the vein's diameter measured overnight as compared to the morning measures - the orthostatic gradient. The obtained results showed that the subacute period of varicophlebitis of the GSV is accompanied and followed by an increase in the diameter of the GSV and SSV and that of their orthostatic gradient, caused by imparted tonicity and viscoelastic properties. Compression therapy alone in the subacute period of varicophlebitis does not provide complete safety of saphenous veins from secondary lesions. Compression therapy combined with a 4-month-long course of taking micronized diosmin increases the efficacy of treatment.

Purpose: To report three cases of solitary, focal retinal phlebitis., Methods: An observational case series., Results: Three eyes in three patients were noted to have unilateral decreased vision, macular edema, and a focal retinal phlebitis, which was not at an arteriovenous crossing. All three patients developed a branch retinal vein occlusion at the site of inflammation. These patients had no other evidence of intraocular inflammation, including vitritis, retinitis, retinal vasculitis, or choroiditis, nor was there any systemic disorder associated with inflammation, infection, or coagulation identified., Conclusion: Focal retinal phlebitis appears to be an uncommon and unique entity that produces macular edema and ultimately branch retinal vein occlusion. In our patients, the focal phlebitis and venous occlusion did not occur at an arteriovenous crossing, which is the typical site for branch retinal venous occlusive disease. This suggests that our cases represent a distinct clinical entity, which starts with a focal abnormality in the wall of a retinal venule, resulting in surrounding exudation and, ultimately, ends with branch retinal vein occlusion.

Background/aim: Multiple sclerosis (MS) is an immune-mediated disorder of the central nervous system (CNS), characterized by inflammation, demyelination and axonal loss. Retinal periphlebitis (RP) is often present in MS patients with similar evolution and histopathological changes as MS lesions. The aim of this study was to analyze the presence of RP in MS patients during different clinical phases, and its connection with impairment of blood-brain barrier., Methods: The study included 45 patients (26 females and 19 males) with MS. Their average age was 33.2 +/- 8.1 years. There were 28 patients with relapsing-remitting (RR) form, 7 with primary progresive (PP) and 10 with secondary progressive (SP) form of MS. There were 27 patients in the relapse and 18 patients in the remission phase. The average MS duration was 7.48 +/- 1.3 years. Ophthalmological, neurological and MRI examination were performed in all the patients, as well as cerebrospinal fluid sampling. Albumin ratio and IgG index were calculated in all the patients., Results: There were 9 patients with RP, and 36 without it. MS duration was significantly longer in the RP group. RP was much more common in the progressive form and was not present in the remission phase of MS. Albumin ratio values were increased in the group with RP. IgG index and IgG synthesis according to Tourtellotte formula, were statistically higher in the group of patients with RP. The values of visual evoked potentials (VEP's) latency were significantly higher in the group of patients with RP., Conclusion: The presence of RP is a reliable indicator of MS activity and might be considered as a parameter for monitoring the disease activity and effects of the treatment.

The main histopathological features in the cutaneous lesions of Churg-Strauss syndrome (CSS) are dermal leukocytoclastic vasculitis with a variable eosinophilic infiltrate and non-vasculitic tissue eosinophilia with granuloma formation. This wide histopathological spectrum may account for the various skin manifestations of CSS. However, the unique histopathological combination of dermal eosinophilic vasculitis and subcutaneous granulomatous phlebitis accompanied by bulla formation has not been previously described. We report an unusual CSS case showing dermal necrotizing eosinophilic vasculitis and granulomatous phlebitis in purpuric lesions coupled with subepidermal blistering. The blisters showed dermal granulomatous dermatitis and eosinophilia without evidence of vasculitis. Dermal necrotizing eosinophilic vasculitis was characterized by fibrinoid alteration of the vessel wall, a prominent perivascular eosinophilic infiltrate, a few infiltrating histiocytes along the affected vessel wall, and the absence of neutrophilic infiltration. The underlying subcutaneous granulomatous phlebitis was characterized by an angiocentric histiocytic infiltrate surrounded by marked eosinophilic infiltrate. Deposition of cytotoxic proteins and radicals derived from eosinophils in the vessel walls and papillary dermis followed by a secondary granulomatous response may account for the unique clinical and histopathological features in this case., (Copyright © 2010 John Wiley & Sons A/S.)

Varicophlebitis is a common disease in the medical practice of dermatologists and phlebologists. In contrast to deep vein thrombosis, which is often associated with pulmonary embolism or other secondary complications, varicophlebitis usually has an uncomplicated course. We present the unusual case of a woman who developed an extensive pulmonary embolism through ascension of a varicophlebitis. Varicophlebitis should not be underestimated; adequate diagnostic procedures, especially via color-coded compression duplex sonography, should be performed and suitable therapy instituted.

Staphylococcus aureus (SA) bacteriuria may accompany SA bacteremia, but primary SA urinary tract infection (UTI) may also occur. Our clinical observation of SA UTIs following intravenous catheter-related phlebitis lead us to review hematogenous and ascending route-related risk factors in patients with primary SA UTIs. The charts from all patients with SA UTIs over a 1.5-year period were reviewed for concurrent or recent hospitalization, intravenous catheterization, and for known UTI risk factors. Patients with concurrent SA bacteremia were excluded. Patients with Escherichia coli UTIs during the same period were included as controls. Twenty cases of primary SA UTI were compared with 43 E. coli UTI cases and they did not differ in age, diabetes mellitus, prostatic hypertrophy, previous UTI, or other urinary tract (UT) abnormality. However, cases were more likely than controls to have had recent or concurrent hospitalization, UT catheterization, and history of recent phlebitis. In multivariate analysis, UT catheterization and recent hospitalization retained significant association with SA UTI. Similar results were shown for the methicillin-resistant SA UTI subgroup. Even though UT catheterization is the main predisposing factor for primary SA UTI, some cases may be mediated through unrecognized preceding bacteremia related to intravascular device exposure or other healthcare-related factors.

Background: To investigate the efficacy of intravitreal injection of triamcinolone acetonide in the management of papillophlebitis and associated cystoid macular edema., Methods: This study was a retrospective medical records review of four eyes of four patients (three males and one female) who had approximately 2-4 months history of papillophlebitis and associated persistent cystoid macular edema. These patients were treated with a single intravitreal injection of 4 mg triamcinolone acetonide. Mean follow-up time was 15 +/- 4 months. The outcome measures included best corrected visual acuity (BCVA), intraocular pressure (IOP), and central retinal thickness by optical coherence tomography (OCT)., Results: The BCVA ranged from 20/100 to 20/60 pre-operation. The mean gain in BCVA was 7 +/- 1 Snellen lines. All eyes had BCVA of 20/20 at the last visit. The mean baseline central retinal thickness as measured by OCT was 529 +/- 53 microm. The mean central retinal thickness by OCT was 235 +/- 15 microm at 1-week follow-up examination. At the last visit the mean central retinal thickness by OCT was 161 +/- 7 microm. One patient experienced an increase in IOP after the first injection and another patient had IOP elevation after the second injection. Both were well controlled with single topical anti-glaucoma medication., Conclusion: Intravitreal injection of triamcinolone acetonide appears to be an effective treatment for patients with papillophlebitis and associated cystoid macular edema.

Introduction: Superficial venous thrombosis (SVT) has been considered for a long time a limited clinical condition with a low importance, but this approach has changed in recent years, when several studies demonstrated spreading to deep veins occurring from 7.3 to 44%, with high prevalence of pulmonary embolism., Materials and Methods: To evaluate the prevalence of genetic risk factors for VTE in patients suffering from SVT on both normal and varicose vein, and to understand their role on spreading to deep veins, we studied 107 patients with SVT, without other risk factors. Ultrasound examination was performed, and the presence of FV Leiden, Prothrombin G20210A mutation, and MTHFR C677T mutation was researched., Results: In the patients where SVT occurred in normal veins, the presence of FV Leiden was 26.3% of the non-spreading and 60% of the spreading to deep veins SVT; Prothrombin mutation was found in 7.9% of the former case and in 20% of the latter; MTHFR C677T mutation was found respectively in 23.7% and 40%. In the patients with SVT on varicose veins, the presence of these factors was less evident (6.7%, 4.4% and 6.7% respectively), but their prevalence was considerably higher (35.7%, 7.4% and 21.4% respectively) in SVT spreading to deep veins than in non-spreading., Conclusions: Our data demonstrate the high prevalence of these mutations, especially FV Leiden and associations, in patients with SVT on normal veins and their role in the progression to deep vein system.

Purpose: A retrospective tertiary care center-based study was undertaken to evaluate the visual outcome in Eales' disease, based on a new classification system, for the first time., Materials and Methods: One hundred and fifty-nine consecutive cases of Eales' disease were included. All the eyes were staged according to the new classification: Stage 1: periphlebitis of small (1a) and large (1b) caliber vessels with superficial retinal hemorrhages; Stage 2a: capillary non-perfusion, 2b: neovascularization elsewhere/of the disc; Stage 3a: fibrovascular proliferation, 3b: vitreous hemorrhage; Stage 4a: traction/combined rhegmatogenous retinal detachment and 4b: rubeosis iridis, neovascular glaucoma, complicated cataract and optic atrophy. Visual acuity was graded as: Grade I 20/20 or better; Grade II 20/30 to 20/40; Grade III 20/60 to 20/120 and Grade IV 20/200 or worse. All the cases were managed by medical therapy, photocoagulation and/or vitreoretinal surgery. Visual acuity was converted into decimal scale, denoting 20/20=1 and 20/800=0.01. Paired t-test / Wilcoxon signed-rank tests were used for statistical analysis., Results: Vitreous hemorrhage was the commonest presenting feature (49.32%). Cases with Stages 1 to 3 and 4a and 4b achieved final visual acuity ranging from 20/15 to 20/40; 20/80 to 20/400 and 20/200 to 20/400, respectively. Statistically significant improvement in visual acuities was observed in all the stages of the disease except Stages 1a and 4b., Conclusion: Significant improvement in visual acuities was observed in the majority of stages of Eales' disease following treatment. This study adds further to the little available evidences of treatment effects in literature and may have effect on patient care and health policy in Eales' disease.

Mesenteric inflammatory veno-occlusive disease is a rare but recognized cause of intestinal ischemia, who can be defined as phlebitis or venulitis affecting mesentery or the bowel, without any evidence of coexisting of an obvious predisposing cause or a coexisting arterial inflammatory involvement. We report the case of a male patient, 63 year old, admitted in the Emergency County Hospital of Craiova, who after presenting with an acute abdomen, underwent exploratory laparotomy and resection of the ischemic sigmoid, temporary colostomy and after four months we reintroduced descendent colon in the digestive transit. The resected specimen of the patient was examined histopathologically, and distinctive histopathological characteristics of the mesenteric inflammatory veno-occlusive disease were identified.

Objective: To study the clinical and pathologic features of ischemic intestinal disease due to mesenteric phlebitis., Method: The clinical and pathologic features of the mesenteric venous lesions in 3 patients of ischemic intestinal disease admitted during the period from 2003 to 2004 were studied., Results: All 3 patients had a clinical history of acute abdominal pain accompanying with a diffuse peritonitis. During operation, an infarcted intestinal segment was identified and was resected respectively in each patient. Histologic examination showed a lymphocytic infiltration and fibrinoid necrosis of the small to medium-sized veins, associated with mural thrombosis and infarction of the corresponding intestinal wall and mesentery. The mesenteric arteries were spared. Two-year follow up of one case showed no evidence of local recurrence or systemic vasculitis., Conclusions: Ischemic intestinal disease due to mesenteric phlebitis is a rare entity with a pathological feature of inflammation of venous wall accompanying with the development of mural thrombosis and subsequent haemorrhagic infarction of intestine. The etiology is unknown and surgical resection of the involved intestinal segment is usually recommended.

We present a patient with a large vegetation in the superior vena cava (SVC) presenting with multiple staphylococcal lung abscesses. We believe that this is the first reported case of vegetative phlebitis of the SVC without a history of central venous catheter line. Our case emphasizes the need for careful imaging SVC using transesophageal echocardiography in bacteremic patients even in the absence of a central catheter.

Enterocolic lymphocytic phlebitis is a rare cause of segmental ischemic enterocolitis. This artery-sparing transmural vasculitis is classically a circumferential phlebitis with perivenular lymphocyte cuffing and thrombi in the absence of systemic manifestations. Myointimal hyperplasia may represent a chronic phase of enterocolic lymphocytic phlebitis. Subclinical or early stage enterocolic lymphocytic phlebitis is not well delineated. We analyzed 600 submucosal and subserosal veins from both ischemic and intact bowel segments to discern if vascular morphology varied between sites. Crescentic and circumferential lymphocytic phlebitis is more common in viable bowel than in the ischemic segment. A nonsignificant trend was found for increased crescentic morphology between intact bowel remote from the ischemic focus compared with that adjacent to the ischemic focus. Hallmarks of ischemic bowel are necrotizing phlebitis and thrombi formation. Thrombophlebitis morphology is distinctly different in viable and ischemic bowel, changing from the classic lymphocytic to necrotizing lesions respectively.

Buerger's disease is an inflammatory occlusive disorder affecting the small and medium-size arteries and veins of young, predominantly male, smokers. The disorder has been identified as an autoimmune response triggered when nicotine is present. Tobacco abuse is the major contributing risk factor; however, smoking seems to be a synergistic factor rather than the cause of the disease. The traditional diagnosis of Buerger's disease is based on 5 criteria (smoking history, onset before the age of 50 years, infrapopliteal arterial occlusive disease, either upper limb involvement or phlebitis migrans, and absence of atherosclerotic risk factors other than smoking). As there is no specific diagnostic test and an absence of positive serologic markers, confident clinical diagnosis should be made only when all these 5 criteria have been fulfilled although not universally accepted. The angiographic findings in Buerger's disease ("corkscrew," "spider legs," or "tree roots") are helpful but not pathognomonic. A wide spectrum of medical or surgical therapeutic options have been proposed; however, total abstinence from tobacco use remains the only means of stopping the disease progression. The initial management of patients with Buerger's disease should be conservative. Because several arteries may be unaffected, claudicants should be encouraged to walk, whereas patients with "critical" ischemia should be admitted for bed rest in the hospital. Bypass grafting is seldom an option, as the location of the lesions distally leaves little to bypass because of lack of target vessels. A literature review revealed only a few series reporting vascular reconstruction (mainly femorodistal bypasses) in Buerger's disease. Bypass patency rates were suboptimal; however, the corresponding limb salvage rates were satisfactory. A possible explanation is that patent grafts, even over a short period of time, are sufficient to allow healing of ulcers in patients with Buerger's disease.

Microscopic colitis is defined as a syndrome of chronic watery diarrhea with a chronic inflammatory cell infiltrate in the colonic mucosa but without significant abnormalities at colonoscopy. It encompasses at least two histopathologic entities (ie, collagenous and lymphocytic colitis). The recognition and characterization of microscopic colitis has markedly changed the approach to the evaluation and management of chronic diarrhea. The histologic features of collagenous and lymphocytic colitis are well known to most pathologists. By considering the clinical history and symptoms, the pathologist should be able to reach the correct diagnosis in most cases. However, the spectrum of morphologic changes associated with watery diarrhea syndrome appears to be broader than originally thought. Morphologic changes more often associated with chronic inflammatory bowel disease or even chronic ischemic or infectious colitis have been noted in patients with clinically established microscopic colitis. The data presented in this article suggest that microscopic colitis is a heterogeneous entity, which includes both classic and "atypical" forms. Problems arise when cases do not fit the usual pattern or lack some of the findings that are expected. Pathologists should be aware of the presence of atypical forms of microscopic colitis.

Enterocolic lymphocytic phlebitis (ELP) is a rare cause of gastrointestinal ischemia. Unlike most vasculitic diseases affecting the gastrointestinal tract, ELP involves only the mural and mesenteric veins, which are surrounded by a lymphocytic and sometimes granulomatous infiltrate. The mesenteric arterial system and the systemic vasculature are characteristically spared. Most patients with ELP present with an acute abdomen that resolves following surgical resection of the involved bowel. ELP has been reported to involve the small bowel, colon, or both, but involvement of the upper gastrointestinal tract has not been previously described. Here we report a case of lymphocytic phlebitis that affected only the stomach and duodenum. The patient, a 68-year-old man, had a nonhealing gastric antral ulcer and underwent hemigastrectomy with vagotomy and Billroth II reconstruction. Both the resected stomach and duodenum showed characteristic lymphocytic and granulomatous infiltrates that involved the submucosal and mural veins, with associated obliteration of vascular lumina; the adjacent arteries were completely spared. The patient developed late postoperative complications including bile reflux gastritis and erosive esophagitis, but he had no recurrence of gastrointestinal ulceration or ischemia over a 2-year follow-up. We hypothesize that there may be more cases of upper gastrointestinal ELP than are diagnosed as such, in part because the diagnosis can be made only on surgical resections specimens.

Two patients with xanthogranulomatous inflammation are described, one with involvement of the spermatic cord and the other with 1 testicle and epididymis affected. To our knowledge, only 12 cases of xanthogranulomatous orchiepididymitis have been reported previously, one of which also presented a xanthogranulomatous funiculitis. Clinically, our patients presented with spermatic cord enlargement (case 1) and chronic orchitis that did not respond to treatment with antibiotics (case 2). Histopathologically, both cases showed extensive xanthogranulomatous inflammation with numerous foamy macrophages that were associated with colonies of microorganisms suggestive of actinomyces in case 1. Additionally, Escherichia coli was cultured from the surgical specimen of case 2. The possible underlying pathology may be diabetes in case 1 and phlebitis associated with chronic orchitis in case 2. Differential diagnoses with other lesions that are rich in macrophages, such as malakoplakia, and those testicular neoplasms without serologic tumor markers are discussed.

We describe a 53-year-old man with a history of diarrhea temporally related to the use of flutamide. He developed an acute abdomen, and presented with an ileocecal intussusception due to an edematous ischemic cecum. The ischemia was due to enterocolic lymphocytic phlebitis (ELP), with numerous associated thrombi. The phlebitis involved not only the ischemic area but also the grossly unaffected areas, including the entire right colon, terminal ileum, and appendix. All layers of the bowel wall were involved. Mesenteric veins were also prominently affected, but the arteries were spared. This rare form of vasculitis was associated with a marked lymphocytic infiltrate involving the epithelium of the entire right colon, ileum, and appendix. This is the first reported case of ELP occurring in conjunction with lymphocytic colitis, lymphocytic enteritis, and lymphocytic appendicitis. The temporal association of the patient's symptoms with flutamide use suggests that this peculiar form of lymphocytic inflammation of the veins and mucosa likely represents a drug reaction. We suggest that some cases of lymphocytic colitis may also be associated with ELP but are unlikely to be recognized unless affected submucosal vessels happen to be included in the biopsy.

A 73-year-old male was referred to our hospital for abdominal pain, diarrhea and general fatigue lasting for 3 weeks. Physical examination of the abdomen revealed a firm mass in the left abdominal region. Computed tomography revealed a mass around the descending colon. Colonoscopy and barium enema revealed poor extensibility of the lumen with edematous mucosa, and narrowing of the descending colon with rugged mucosal surface. Because of the clinical symptoms and findings, the patient was diagnosed clinically as suffering from panniculitis of the descending colon. He underwent the left hemi-colectomy with side-to-side colo-colostomy after making of a loop ileostomy. Histological analysis of the resected colon showed an infiltration of inflammatory cells, predominantly lymphocytes, into veins and venules of the submucosa, muscularis propria and fat tissue of the colonic mesentery, with an involvement of all layers of the vessel wall. Arteries were escaped from inflammatory changes. The histopathological diagnosis of enterocolic phlebitis and venulitis was made because of these findings.