British Journal of Radiology (2004) 77, 888-890
© 2004 British Institute of Radiology
doi: 10.1259/bjr/32956594
Internal and external jugular vein thrombosis with marked accumulation of FDG
M Kikuchi, MD
1
E Yamamoto, MD
2
Y Shiomi, MD
1
Y Nakamoto, MD
3
Y Shiomi, MD
1
K Fujiwara, MD
1
F Watanabe, MD
1 and
S Shinohara, MD
1
1 Department of Otolaryngology, Kobe City General Hospital, Kobe, 2 Yamamoto Ear Surgicenter, Osaka and 3 Institute of Biomedical Research and Innovation, Kobe, Japan
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Abstract
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We report an unusual case of idiopathic internal and external jugular vein thrombosis. Positron emission tomography (PET) using 18F-fluoro-2-deoxy-D-glucose (FDG), which was conducted to assess subclinical malignancy, revealed intense uptake of FDG, corresponding to thrombus within the left internal and external jugular veins. Although FDG-PET is widely used in differentiating between malignant and benign diseases, we should bear in mind that this benign entity can demonstrate high accumulation of FDG.
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Case report
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A 56-year-old male patient, who had been diagnosed with left internal jugular vein thrombosis, showed swelling around the left parotid gland. Although he had been given anticoagulation therapy with warfarin potassium, the swelling increased and was associated with fever and tenderness. Examination revealed an indurated mass below the left ear with an ill-defined margin. Blood tests showed high white blood cell count and C-reactive protein levels of 12 300 mm–3 and 10.4 mg dl–1, respectively.
Serum amylase performed to exclude parotiditis was normal. No pathogens were identified from swabs taken from the pharynx. Blood cultures were negative. There was no evidence clinically of any other areas of infection or inflammation in the head and neck. A contrast-enhanced CT scan demonstrated a high-density lesion in the left parotid gland and ring-shaped enhancement of the left retromandibular vein. Appearances in the left external and internal jugular indicated the presence of thrombus within the veins (Figure 1
). Antibiotic therapy was started, based on the diagnosis of phlegmon below the left ear accompanied by thrombophlebitis. Ultrasound and MR venography also supported the diagnosis of thrombosis in internal and external jugular veins. In order to exclude subclinical malignancy, a FDG-PET scan was performed 1 month after the initial event (2 weeks after the end of antibiotic therapy). After intravenous administration of 135 MBq of FDG, emission and transmission scans of the whole body were obtained using an ECAT EXACT 47 scanner (Siemens/CTI, Knoxville, TN). Attenuation-corrected PET images showed marked accumulation of FDG at the site of thrombosis with a standardized uptake value (SUV) of 10.4 (Figure 2). To exclude tumour thrombus, biopsy of the left external jugular vein was conducted. The histological diagnosis was of thrombosis infiltrated by inflammatory cells (Figure 3). No malignant cells were identified.
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Figure 1. (a) A CT image reveals ring-shaped enhancement and central low density in the left retromandibular vein (arrow), suggesting venous thrombosis. On more caudal level, vascular enhancement is not observed due to the thrombus both in (b) the left external jugular vein (arrow) and (c) the left internal jugular vein (arrow).
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Figure 2. Intense uptake of 18F-fluoro-2-deoxy-D-glucose (FDG) corresponding to lesions suspected of thrombus formation in the left internal and external jugular veins. Continuous accumulation ranged from the area adjacent to the left parotid gland to the insides of two veins (arrows).
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Figure 3. Histological features (haematoxylin and eosin staining) of the left external jugular vein. (a) A whole section of the vein, (b) peripheral portion and (c) central portion are demonstrated. The lamellar structure of venous wall was destroyed and collagenous fibres intruded inside from the wall. No cancer cells were detected in the organized thrombus. Infiltration by foam cells and lymphocytes can clearly be observed in the margin, whereas plasma cells and neutrophils are predominantly recognized in the central area.
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The patient underwent another FDG-PET scan 3 months later, which was normal with resolution of the previously abnormal findings. The patient has remained well during the 10 month follow-up period.
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Discussion
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Phlebothrombosis is often seen in the lower extremities and pelvis, where the blood flow frequently stagnates [1]. It rarely develops in the cervical area. Internal jugular vein thrombosis accompanied by inflammation of the neck [2] and thrombosis of sigmoid sinus complicated by otitis media [3], have been reported, but the prevalence is extremely low because of advances in antibiotic therapy. The incidence of internal jugular vein thrombosis caused by intravenous catheterization is reported to be on the rise, and up to 65% of patients who undergo intravenous catheterization are reported to be affected [4].
In this case, the patient had no history of traumatic injury nor surgical procedure in the neck. Furthermore, there were no signs that the veins were compressed by tumour. CT showed slightly a lesion with moderately increased density in the left parotid gland and suggested parotiditis had existed. However, there was no evidence of any purulent discharge from the left parotid duct, serum amylase level was within the normal range and there was no increased uptake of FDG associated with the left parotid gland was not detected, although the scan was performed some weeks after initial symptoms.
Accordingly, parotiditis did not seem likely to be the cause of thrombus formation but to be a secondary symptom resulting from the thrombophlebitis. The underlying cause of the thrombus could have been infective. However, as no other areas of inflammation or infection were present in the head and neck region and blood culture and swab of the pharynx were negative for bacteria, we consider that this case was likely to be idiopathic rather than infective.
Lieberman et al studied 81 patients concomitantly suffering from phlebothrombosis and malignant tumour and recognized that detection of phlebothrombosis was earlier than that of malignant tumour in nearly 60% of the patients [5]. In approximately 50% of these patients, the malignant tumour was discovered between 2 and 6 months after the initial finding of phlebothrombosis, while more than a year elapsed before the malignant tumour was found in 6 patients. They have suggested that malignant tumour should be considered a subclinical disease in cases with thrombosis of unknown origin. Lung cancer, pancreatic cancer and gynaecological malignancies may promote coagulation by factor VIII or thromboplastin, produced by tumour cells. In these cases, phlebothrombosis tends to be recurrent and migratory and shows resistance to anticoagulant therapy. The sites of predilection for this disease are the veins of the arm and neck.
There are a few reports describing phlebothrombosis with FDG accumulation [6, 7]. However, we found no cases of marked accumulation of FDG comparable with the present case. Therefore, to exclude the possibility of tumour thrombus, biopsy of the left jugular vein was performed. Histopathological examination demonstrated idiopathic thrombosis severely infiltrated by inflammatory cells with no malignancy. However, long term follow-up will be necessary to rule out subclinical malignancy [5].
It is known that FDG accumulates in inflammatory and infectious lesions [8]. It is also reported that inflammatory cells cause significant increase in glucose uptake in the presence of platelet aggregating factors and cytokines, including growth factors [9]. It is, therefore, quite reasonable for venous thrombus infiltrated by inflammatory cells to also be FDG-avid. And in the present case, a local increase in platelet aggregating factors might have contributed further to FDG uptake. It may be difficult to differentiate between tumour thrombus and venous thrombus by FDG-PET only.
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Conclusion
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We reported a case of idiopathic internal and external jugular vein thrombosis with accumulation of FDG. It should be noted that for venous thrombus infiltrated by severe inflammatory cells, FDG can accumulate to a marked extent.
Received for publication October 23, 2003.
Revision received February 2, 2004.
Accepted for publication March 30, 2004.
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