December 23, 2024

66-year-old woman with a history of small-cell lung cancer presents for leg pain and swelling

By Med-Challenger · 2 minute read

A 66-year-old woman with a history of small-cell lung cancer presents for evaluation of left leg pain and swelling that started yesterday. She notes no falls or trauma and notes no chest pain or shortness of breath or hemoptysis. She has had no major bleeding events in the past. She does not smoke cigarettes, drink alcohol, or use illicit drugs. She does not take any medications and does not have any allergies.

Her vital signs are: blood pressure 110/80 mm Hg, pulse 75 beats/minute, respiratory rate 14, oxygen saturation 100% on room air, and temperature 99 °F. General physical examination is remarkable for left leg swelling to the inguinal region. The leg is cyanotic and dorsalis pedis and poster tibial pulses are hard to elicit.

A complete blood count, serum chemistries, and coagulation studies are obtained, and the results are within normal limits. Venous Doppler ultrasonography is obtained and shows massive iliofemoral deep venous thrombosis (DVT).

What is the next step in the management of this patient's condition?

Initiate therapy with warfarin.
Initiate therapy with unfractionated heparin.
Initiate therapy with low molecular weight heparin and consult vascular surgery/interventional radiology for possible thrombolysis or thrombectomy.
Initiate therapy with rivaroxaban.

The correct answer is:

Initiate therapy with low molecular weight heparin and consult vascular surgery/interventional radiology for possible thrombolysis or thrombectomy.

Educational Objective:

Recognize and manage the manifestations of phlegmasia cerulea dolens.

Key Point:

Phlegmasia cerulea dolens is due to a deep venous occlusion and can lead to limb ischemia.

Explanation:

This patient developed phlegmasia cerulea dolens due to massive iliofemoral DVT that occluded the venous drainage of her leg that, in turn, can cause compartment syndrome, gangrene, and limb ischemia. The next step in the management of this patient's condition would be to initiate therapy with low molecular weight heparin. and to obtain an interventional radiology consultation for the possible need for thrombolytic therapy or thrombectomy. Some patients will respond promptly to heparin along with supportive measures such as elevation of the affected leg and fluid resuscitation.

Neither warfarin nor dabigatran (an oral direct thrombin inhibitor), would be appropriate in this setting given their longer-lasting effects and the possible need for emergent intervention. Low molecular weight heparin is preferred over unfractionated heparin.

References:

Lip G, Hull R. Overview of the treatment of lower extremity deep venous thrombosis (DVT). Revised June 15, 2017. Accessed October 3, 2017.

Meissner MH, Gloviczki P, Comerota AJ, et al. Early thrombus removal strategies for acute deep venous thrombosis: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2012;55:1449.

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