Diagnose on Sight: Swollen Leg

Jun 14, 16
Diagnose on Sight: Swollen Leg

Phlegmasia Cerulea Dolens_1 editedCase: A 58 year-old female presents with a one-day history of worsening right lower extremity pain and swelling, and an acute onset of dyspnea. Her past medical history consists of stage IV renal cell carcinoma diagnosed six months previously. Triage vitals are remarkable for a heart rate of 120 beats per minute and a blood pressure of 68/48 mmHg. What is the diagnosis?


Poll Results

[plot id=”1″]

[su_spoiler title=”Answer” style=”fancy” icon=”caret”]

Phlegmasia Cerulea Dolens


Phlegmasia cerulea dolens is a rare syndrome of acute massive venous thrombosis of the lower extremities. The classic clinical triad includes acute ischemic pain, limb swelling, and a blue or violaceous discoloration of the skin.1 Underlying malignancy is present in approximately one third of patients.1,2 Other risk factors include:

  • Presence of a hypercoagulable syndrome
  • Venous stasis
  • Use of contraceptive agents
  • Inferior vena cava filter insertion

This disease process carries a high-risk morbidity and mortality.

Important considerations:1–3

  • Venous gangrene 40-60%
  • Amputation 20-50%
  • Concomitant pulmonary embolism 29%
  • Mortality up to 40%

Management priorities include stabilization of the patient and aggressive management of the venous thrombus for life and limb preservation. Due to the relative infrequency of cases, there is no consensus regarding optimal treatment, and a wide variation of techniques have been used including systemic anticoagulation and thrombolysis, surgical thrombectomy, and more recently percutaneous mechanical thrombectomy and catheter guided thrombolysis.3,4 Urgent specialist consultation in the ED is advised to assist in managing this dangerous condition.

Case Conclusion

Point of care ultrasound demonstrated septal deviation and right ventricular dilation on apical four chamber view, and a deep venous thrombosis in the lower extremities. A chest CT confirmed bilateral pulmonary emboli. The patient was admitted to the intensive care unit for stabilization and the Thrombosis and Interventional Radiology teams were consulted for assistance in acute management.


Master Clinician Bedside Pearls

Mark Reardon, MD FRCP  
Assistant Professor of Emergency Medicine
University of Ottawa

Chinsakchai K, Ten D, Moll F, de B. Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg. 2011;45(1):5-14. [PubMed]
Onuoha C. Phlegmasia Cerulea Dolens: A Rare Clinical Presentation. Am J Med. 2015;128(9):e27-8. [PubMed]
Kearon C, Akl E, Comerota A, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e419S-94S. [PubMed]

Author information

Peter Reardon, MD

Peter Reardon, MD

Emergency Medicine Resident
University of Ottawa

The post Diagnose on Sight: Swollen Leg appeared first on ALiEM.

Leave a Comment

Like articles like this one?

Join our Email List and get the latest TCCC/TECC/TEMS news bulletins, articles, product releases, and more!

Free Delivery

On all orders over $99 within CONUS and to APO/FPO

Easy Returns

We're here to help! Satisfaction Guaranteed

Knowledgeable Staff

Ready to assist you at a moment's notice

Safe& Secure Checkout

World’s most advanced and secure website encryption.