Instant thrombophlebitis diagnosis with point-of-care ultrasound (POCUS)

A middle-aged woman admitted to the hospital for congestive heart failure began having fevers. Blood cultures, urinalysis, and chest imaging were all negative for infection. The following morning, she developed pain and tenderness in her right cubital fossa at the site of a prior IV. On exam, it is erythematous, tender to touch and firm.

Point-of-care ultrasound (POCUS) exam revealed the following:

Thrombophlebitis is a condition in which a blood clot forms within a vein and triggers inflammation of the vein wall. It most commonly affects superficial veins just beneath the skin, especially in the legs, where it often presents as localized pain, redness, warmth, and a firm, tender, cord-like structure along the course of the vein.

With point-of-care ultrasound (POCUS), a normal vein should fully collapse under gentle probe pressure, whereas a thrombosed vein will remain noncompressible. There will also be an absence of flow with color Doppler, and as in this case, you can see some echogenic material inside the cephalic vein. You can sweep up and down the vein to determine the extent of the thrombus. The surrounding tissue shows inflammatory edema, evident as hypoechoic separations in the subcutaneous tissue, called "cobblestoning."

Treatment of thrombophlebitis depends on the location, extent, and risk profile of the patient. Most uncomplicated cases of superficial thrombophlebitis can be managed conservatively with nonsteroidal anti-inflammatory drugs, warm compresses, compression therapy, and continued ambulation, with symptoms typically improving over one to two weeks.

Anticoagulation can be considered when the clot is extensive, rapidly progressing, close to the deep venous system, or occurring in patients with higher thrombotic risk, such as those with prior venous thromboembolism, active cancer, pregnancy, or known thrombophilia. In these cases, short-term anticoagulation is often used to reduce the risk of clot propagation.