Blues clues

A 70-year-old female with recently diagnosed extramedullary acute myeloid leukemia (AML) presented with severe shortness of breath and chest pain found to have a massive pulmonary embolism. On physical examination, the patient had acute phlegmasia cerulea dolens (painful blue edema) of her left lower extremity (Figures 1 and 2) secondary to extensive bilateral deep vein thrombosis (DVT) up to the proximal common iliac veins. Occlusive deep vein thrombosis of right common femoral vein (Figure 3) and that of left external iliac vein (Figure 4) are visible on Doppler ultrasound.

Figure 1.

Patient with blue edema of the left lower extremity secondary to extensive deep venous thrombosis.

Figure 2.

Patient with blue edema of the left lower extremity secondary to extensive deep venous thrombosis.

Figure 3.

The patient with extensive occlusive deep venous thrombosis of right common femoral vein on ultrasound imaging.

Figure 4.

The patient had occlusive deep venous thrombosis of left external iliac vein on ultrasound imaging.

Phlegmasia cerulea dolens is an uncommon, severe deep venous thrombosis arising from occlusion of both major and collateral veins of a limb. Patients complain of sudden extreme pain, swelling, edema and bluish/purplish discoloration of the affected extremity. Like in our patient, 50% are associated with an underlying malignancy and it can lead to massive pulmonary embolism or gangrene.

Unfortunately, the patient did not survive despite immediate anticoagulation.

Informed Consent: The patient consented to all authors the use of photographs and publication of this image report.