Tuesday, October 24, 2006

I'm feeling phlegmy...

Here's an interesting case that I just had making a "sexy diagnosis" (at least to pin-heads like myself and "the little ball of hate" aka Evan)...

CC: "Leg Swelling"
HPI: 39 yo caucasian male presents w/ RLE pain. Significant h/o recent dx of RLE DVT (per pt appeared to be isolated to the popliteal region). While admitted he was also dx'd w/ B/L pulmonary embolism. Pt has been on Coumadin, but has not had it checked since his discharge from the hospital (one week prior). He has chronic SOB (secondary to morbid obesity and tobacco abuse). No new CP or SOB.

Patient primarily complains of new RLE pain and it being cyanotic. This acutely (per pt) started around 6 hours PTA. Now he has significant pain w/ any ROM of the leg, it's entirely purple and swollen. No new trauma to the area. The swelling now encompasses the entire RLE (where it was isolated to the popliteal region originally).

PMHx: DM, PE, RLE DVT, morbid obesity, CAD
Meds: Coumadin, oxycodone, Glucophage, nitroglycerin, Aleve
PSHx: Cardiac cath
SHx: Married
ROS: As above, otherwise nothing significant
V/S: BP: 145/86, pulse 95, RR: 20, Temp: 97.9 degrees, Sats: 98%
PE: Obese male on a gourney in quite a bit of discomfort, nontoxic.
Pertinent findings: Mottled w/ cyanotic changes to the entire, edematous RLE. Exquisitely TTP everywhere through the entire RLE. +2 DP/PT, but even this causes significant pain. No other significant PE findings.

So with this history and presentation, what sexy diagnosis came to my mind?

Possible Dx: Phlegmasia cerulea dolens

Phlegmasia cerulea dolens is a massive iliofemoral deep venous thrombosis. In this patient I was concerned about his lack of f/u on his INR and presumed that he was subtherapeutic. This could lead to propogation of the DVT. If allowed, this condition can cause arterial compromise and a compartment syndrome type picture (one that was becoming evident on exam). Remember, that with compartment syndrome, loss of arterial pulses is a LATE finding (too late). So while he has palpable pulses, this acute, edematous, cyanotic leg is consistent with this diagnosis. If pulses are lost the leg becomes doughy white and pallorous - this is referred as phelgmasia cerluea albans.

So as I left the room, I placed a call to vascular surgery stat. Spoke w/ the surgeon on call and I was able to get interventional radiology to come in w/ the vascular surgeon in order to perform a thrombectomy. The patient was about six hours into the event and was at risk for limb ischemia. As it happened, the patient's INR was 1.08 and he had been evaluated for hypercoagulable state.

Other possibilities in the DDx would be aortic dissection.

The patient went to IR, the thrombectomy was performed and he went to the ICU on heparin. Currently the patient is still admitted and now has a pink, only mildly edematous leg.

Hope this was of educational value.


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