Clinical, Visual Diagnosis

Blue Leg

The Patient

A 46-year-old male presents to the emergency department complaining of excruciating right leg pain. The pain began with a mild aching the day prior to admission along with some diffuse swelling of the leg, but has quickly progressed over the past few hours to severe diffuse 10/10 pain and worsening lower extremity swelling. The patient has no medical problems and has never had anything like this before. His physical exam is remarkable for a regular tachycardia to 124 beats per minute, and the findings depicted in the image provided.

What is the diagnosis?

Phlegmasia Cerulea Dolens

The clinical findings in this patient are consistent with phlegmasia cerulea dolens. Phlegmasia cerulea dolens (PCD) is a condition that results from a massive diffuse venous thrombosis that results in acute venous outflow obstruction. In this patient, duplex ultrasonography revealed extensive thrombus from the groin extending all the way to the distal lower extremity. Patients typically present with significant pain, swelling, and cyanosis of the affected extremity. Given the potential for limb ischemia, emergent vascular surgery consultation should be considered. Treatment may include anticoagulation, catheter directed thrombolysis, and/or surgical thrombectomy along with pain control. As with any thrombotic process, Virchow's Triad (stasis, endothelial damage, and hypercoagulable states) helps to generate a differential diagnosis. Unfortunately in this patient, this was the initial presentation of severe metastatic cancer.