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Clinical Images

The Painful Blue Limb


blue limb.JPG

Authors: Prasanna Sengodan MD1, Mohammad Alomari MD1, Siddharth Dugar MD2

 

1: Department of Internal Medicine, Cleveland Clinic at Fairview Hospital, Cleveland, Ohio

2: Department of Critical Care, Respiratory Institute, Cleveland Clinic Foundation, Ohio

                A 65 year old woman with past medical history of hypertension, coronary artery disease, diabetes mellitus and recent left humerus fracture status-post open reduction and internal fixation three weeks prior presented with left lower extremity stabbing pain and swelling of one day duration. The pain was associated with decreased sensation and bluish discoloration of the left lower extremity. Physical examination revealed stable vital signs, but the left leg was markedly swollen with bluish discoloration (Figure 1); distal pulses were intact.  Laboratory work up was remarkable for total creatinine kinase of 1318 IU/L and serum myoglobin of more than 3000 IU/L.  An urgent left lower extremity venous duplex was performed and is shown in Figure 2 as a longitudinal ultrasound section, demonstrating a dilated and enlarged left common femoral vein.

What is the most appropriate next step in management?

  1. CTA of the Chest

  2. Conservative medical treatment with bed rest, leg elevation and IV Heparin infusion

  3. IV Heparin infusion and catheter directed thrombolysis

  4. Systemic thrombolysis

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Figure Legends

Figure 1: Diffuse swelling of the left lower extremity associated with bluish discoloration

Figure 2: Urgent left lower extremity venous duplex in longitudinal section demonstrating a dilated and enlarged left common femoral vein.

References

  1. Perkins JM, Magee TR, Galland RB. Phlegmasia cerulea dolens and venous gangrene. Br J Surg 1996;83:19-23. 

  2. Qvarfordt P, Eklof B, Ohlin P: Intramuscular pressure in the lower leg in deep vein thrombosis and phlegmasia cerulea

     

  3. Sloane PD, Baldwin R, Montgomery R et al. Left-sided leg edema of the elderly: a common variant of the iliac compression syndrome. J Am Board Fam Pract. 1993 Jan-Feb;6(1):1-4

     

  4. Patel NH, Plorde JJ, Meissner M. Catheter-directed thrombolysis in the treatment of phlegmasia cerulea dolens. Ann Vasc Surg. 1998 Sep;12(5):471-5

     

  5. Tung CS, Soliman PT, Wallace MJ et al. Successful catheter-directed venous thrombolysis in phlegmasia cerulea dolens. Gynecol Oncol. 2007 Oct;107(1):140-2

     

  6. Hadi Rokni Yazdi, Nematollah Rostami, Homa Hakimian et al. Successful Catheter-Directed Venous Thrombolysis in an Ankylosing Spondylitis Patient with Phlegmasia Cerulea Dolens. Iran J Radiol. 2013 Jun; 10(2): 81–85

Author Bios:

Prasanna Sengodan MD is an internal medicine resident at the Cleveland Clinic Foundation at Fairview Hospital.

Mohammad Alomari MD is an internal medicine resident at the Cleveland Clinic Foundation at Fairview Hospital.

Siddharth Dugar MD is an associate staff physician in the Department of Pulmonary Critical Care at the Cleveland Clinic Foundation.