CASE 10121 Published on 04.06.2012

Infected groin thrombus



Case Type

Clinical Cases


Ghouri MA, Nyhsen C

City Hospitals Sunderland
Sunderland, United Kingdom

32 years, male

Area of Interest Cardiovascular system, Thorax, Lung ; Imaging Technique CT-Angiography, CT
Clinical History
A 32-year-old male patient, former intravenous drug user presented to the emergency department with a painful swollen left leg and dyspnoea. Clinical examination showed a swollen left leg with a discharging sinus in the groin. There was no erythema or signs of cellulites. Blood tests showed raised inflammatory markers and d-dimer.
Imaging Findings
CT examination of abdomen and pelvis showed a left common iliac vein thrombus containing gas bubbles associated with perivascular stranding (Fig. 1, 2). Irregular thickening of left external iliac and femoral vein with regional lymphadenopathy was also noted (Fig. 3). Appearances were consistent with an infected thrombus in left common iliac vein.

A CT pulmonary angiogram performed 7 days later demonstrated small branch occlusive and non occlusive thrombo-embolic disease. There were several cavitating lesions peripherally in both lung fields consistent with lung abscesses, as well as a left pleural effusion and mediastinal lymphadenopathy (Fig. 4).
Clinical Perspective:
The ilio-femoral segment is commonly used by intravenous drug abusers when all other available superficial veins have become thrombosed, thereby making it a common site for deep venous thrombosis (DVT) [1]. The incidence of vascular complications in intravenous drug abusers has increased over the years [2].

Imaging Perspective:
Computed Tomography (CT) can help diagnose vascular infections, which can present in numerous ways and if left untreated can be life-threatening. The specific CT findings for acute DVT include increase in size and attenuation of the veins in unenhanced CT [3, 4]. Sometimes hyperattenuating signs may be the only unique finding indicating an acute DVT [5]. Presence of an intravenous filling defect is highly suggestive for DVT in contrast enhanced CT, however, the possibility of flow artefact should always be considered [3, 4]. The presence of gas bubbles within the thrombus increases the suspicion of infection on the CT [6].

Aggressive treatment with antibiotics and anticoagulants is often required. Heparin or low-molecular weight heparins are standard thrombolytic therapies accepted globally. Catheter-directed intravenous therapy seems to be more effective than systemic administration of thrombolytic agents [7, 8]. Mechanical thrombectomy by percutaneous endovascular technique is a new adjuvant alternative treatment [9]. This can be carried out using off-label rheolytic thrombectomy devices like Angiojet ™ (MEDRAD, Inc. PA, USA).

Early recognition of infected deep vein thrombosis and prompt treatment with appropriate antibiotics and anticoagulation is essential to prevent life-threatening complications.
Differential Diagnosis List
Infected left common iliac vein thrombus with secondary PE and lung abscess
Infected thrombus
Final Diagnosis
Infected left common iliac vein thrombus with secondary PE and lung abscess
Case information
DOI: 10.1594/EURORAD/CASE.10121
ISSN: 1563-4086