the diagnosis of septic pelvic thrombophlebitis is frequently one of exclusion ; a suspicion should arise when fever fails to respond to standard broad - spectrum antibiotic therapy and defervesces within 48 hours of the addition of systemic anticoagulation . we report the first case of septic pelvic thrombophlebitis following laparoscopic hysterectomy in a 51-year - old woman who developed fever on postoperative day 4 . a clinical diagnosis of septic pelvic thrombophlebitis was made , and the patient responded excellently to anticoagulation in conjunction with antibiotic therapy . although rare , septic pelvic thrombophlebitis should be suspected after laparoscopy in patients with appropriate risk factors and persistent fever despite antibiotic therapy . considerable benefit will be derived from clinical trials that study and provide data on the risk and incidence of thromboembolism after laparoscopic procedures . septic pelvic thrombophlebitis ( spt ) was initially described at the end of 19th century . the entity was then frequent and resulted in a 50% rate of mortality . since then , with a better understanding of the pathophysiology of the disease and the availability of new drugs , management has evolved greatly and the incidence has been reduced . the treatment of spt has switched from a surgical excision or ligation of the thrombosed veins to a medical approach . two types of septic pelvic thrombophlebitis ( spt ) have been described : ovarian vein thrombophlebitis ( ovt ) and deep septic pelvic thrombophlebitis ( dspt ) . typically , patients with spt present with fever within 1 week of delivery or surgery . septic workup fails to identify the origin of the fever , which persists despite large - spectrum antibiotics . addition of systemic anticoagulation resolves the fever within 48 hours . to the best of our knowledge in the english - language literature we report the first case of spt occurring 4 days after a total laparoscopic hysterectomy . a 51-year - old female with previous left salpingo - oophorectomy underwent a difficult laparoscopic hysterectomy with right salpingo - oophorectomy for extensive endometriosis and menometrorrhagia . her past medical history was significant for type 2 diabetes , hypertension , hypothyroidism , adrenal insufficiency , and a bmi>30 . the patient had transient unexplained asymptomatic sinusal tachycardia up to 124 beats per minute during the first postoperative night , which improved spontaneously . the patient came back on postoperative day 6 ( pod ) reporting fever and chills since pod4 , which had gradually worsened . she denied any respiratory or urinary symptoms , calf pain , abdominal pain , or vaginal discharge . chest radiography , urine culture , hemoculture , and clostridium difficile essay were negative , and white blood count was normal . she was started on intravenous antibiotic therapy ( ampicillin , gentamicin , and clindamycin ) for suspected infected vaginal vault hematoma . a pelvic tomodensitometry confirmed a small triangular structure in the pelvis near the sigmoid colon . the internal medicine department was consulted for evaluation of diarrhea and resulting hypokalemia as well as suboptimal glycemic control . in the absence of improvement of the fever , the infectious disease department was also consulted , and antibiotic therapy was changed to zosyn . the patient was subsequently taken to the operating room on pod11 for a diagnostic laparoscopy . as persistent fever spikes were not otherwise explained , a clinical diagnosis of septic pelvic thrombophlebitis was suspected . on pod12 , heparin therapy was added to the intravenous antibiotic regimen . from this point , , both medications were stopped , and the patient was discharged home in stable condition . the pathophysiology of spt was initially described in a cohort of 70 women with fever following obstetric or gynecologic procedures in 1951 . the diagnosis was confirmed in each case by exploratory laparotomy , which demonstrated grossly palpable intravenous thrombus and seropurulent fluid . clinically , patients with spt usually present with fever within 5 days of delivery or surgery , but the onset may be delayed to up to 3 weeks following the event . abdominal or pelvic tenderness is notably absent , and patients usually appear clinically well between fever spikes . numerous factors confer increased risk for spt , such as pregnancy ( 1 in 3000 ) , cesarean delivery ( 1:800 compared with 1:9000 for vaginal delivery ) , pelvic infection , induced abortion , pelvic surgery , uterine fibroids , underlying malignancy , and hormonal stimulation . those conditions create an environment where the 3 components of virchow 's triad for the pathogenesis of thrombosis ( hypercoagulable state , venous stasis , and endothelial damage ) are present . radiographic imaging , such as computed tomography or magnetic resonance imaging , can reveal ovt but is virtually useless for visualizing dspt . leukocytosis is modest , and hemocultures are positive in less than a third of cases revealing mainly gastrointestinal flora . suspicion should arise in patients at risk when spiking fever fails to respond to broad - spectrum intravenous antibiotic therapy . the resolution of fever within 48 hours of empiric systemic anticoagulation should confirm the diagnosis . anticoagulation is advocated for the management of spt to a goal ptt of 1.5 to 2.0 times the patient 's baseline . if spt or emboli are documented radiologically , anticoagulation should be continued for a longer period . in the absence of documented clot or underlying thrombophilia , most clinicians favor discontinuing heparin following resolution of fever for at least 48 hours . selection of antibiotics for management of spt is extrapolated from literature addressing postpartum endometritis and should include activity against enterobacteriaceae , anaerobes , and streptococci . review of the english - language literature reveals no reports of previous cases of spt associated with laparoscopic surgery . the incidence of perioperative deep and superficial thrombophlebitis is lower after however , data are limited and evidence - based guidelines regarding the need for thromboprophylaxis during laparoscopic surgery in gynecology are still lacking . there is substantial variability in the current practices regarding deep venous thrombosis prophylaxis for minimally invasive surgery . considerable benefit could be derived from clinical trials studying the risk of dvt during different laparoscopic gynecologic surgeries and the benefit to expect from prophylaxis . a high index of suspicion is the cornerstone in the management of patients with septic pelvic thrombosis . it seems that minimally invasive surgery may contribute to its pathogenesis and should be considered as a risk factor in high - risk patients with compatible clinical presentation . we hope that this case report can help physicians become aware of this rare but serious complication and to avoid delay in diagnosis and treatment .
background : the diagnosis of septic pelvic thrombophlebitis is frequently one of exclusion ; a suspicion should arise when fever fails to respond to standard broad - spectrum antibiotic therapy and defervesces within 48 hours of the addition of systemic anticoagulation . the risk of a thromboembolic event following minimally invasive surgery is not well defined.case report : we report the first case of septic pelvic thrombophlebitis following laparoscopic hysterectomy in a 51-year - old woman who developed fever on postoperative day 4 . 
 the fever workup was negative . 
 the patient 's temperature spikes were unresponsive to medical management . 
 a clinical diagnosis of septic pelvic thrombophlebitis was made , and the patient responded excellently to anticoagulation in conjunction with antibiotic therapy.conclusion:although rare , septic pelvic thrombophlebitis should be suspected after laparoscopy in patients with appropriate risk factors and persistent fever despite antibiotic therapy . 
 considerable benefit will be derived from clinical trials that study and provide data on the risk and incidence of thromboembolism after laparoscopic procedures .