A 32-year-old male was presented to the emergency department because of ulcers, eschars, and multiple reddish nodules on both arms for five days, which developed after scratching both arms owing to severe pruritus. The patient’s medical history revealed only job-related stress with occasional onychophagia. The patient denied drug abuse, abroad stays, allergies, or animal contact. Physical examination revealed ulcers of the left elbow with hardened, tender, and darkish nodules and eschars along the major superficial veins of the upper limbs (Figure 1). Duplex sonography revealed bilateral thrombophlebitis of the right median antebrachial vein and cephalic and median cubital veins (Figure 2). Elevated C-reactive protein (140 mg/L) level, leukocytosis (19.95 x 109/L), and neutrophil count (12.0 x 109/L) were detected in laboratory testing; however, the assessment of drug screen, urine analysis, antibodies against human immunodeficiency virus and hepatitis B and C, cryoglobulins, autoantibodies, chest radiography, and psychiatric were unremarkable. Repeated wound swabs of the ulcers were positive for group G streptococci, Arcanobacterium haemolyticum, Staphylococcus aureus, and Prevotella disiens but negative for mycobacteria and fungi. Blood cultures remained negative. Given the presence of eschars along thrombophlebitis and different bacterial species in the wound swabs, the patient was diagnosed with necrotizing polymicrobial thrombophlebitis. Amoxicillin/clavulanic acid 1 g twice daily for 2 weeks with consecutive decreasing inflammation parameters and enoxaparin 40 mg once daily for 6 weeks were administered. Skin and vein changes healed without reoccurrence after six weeks.
Staphylococcus aureus and Streptococci are common pathogens of thrombophlebitis, whereas Arcanobacterium haemolyticum and Prevotella disiens may be members of common oral microflora, which may also lead to soft tissue infections.1-3 In this case, potential transmission of both anaerobes via onychophagia with subsequent superinfection of scratch artifacts may occur, which leads to necrotizing thrombophlebitis.
Patient Consent for Publication: The authors declare that they could not obtain verbal or written consent from the patient, as the patient could not be reached by phone.
Author Contributions: Concept – P.J.; Design – J.P., P.J.; Data Collection or Processing – J.P.; Analysis or Interpretation – J.P.; Writing - J.P., P.J.
Conflict of Interest: No conflict of interest was declared by the authors.
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