NEJM: CLINICAL PROBLEM-SOLVING
Kurdistan GEH Board journal club:
A 55-year-old man with a history of heart failure presented to the
emergency department with pain and swelling in his right foot and
Three days beforepresentation, he noted a sudden onset of
swelling in the right foot and calf, without any prior trauma.
The swelling worsened progressively, extending to the upper
leg&was accompanied by pain in the foot and calf.
He doubled his usual dose of torsemide, with no effect.
On the day of presentation, he noted new dusky discoloration of
the toes on his right foot.
The patient’s medical history was notable for obesity, paroxysmal atrial
fibrillation, hypertension& heart failure with a preserved ejection fraction.
Medications included warfarin, sotalol, torsemide, and lisinopril.
There was no personal or family history of arterial or venous thrombosis.
The patient had a 30-pack-year smoking history but had quit smoking 5
years earlier. He drank about four beers every weekend.
He reported an intentional weight loss of 22.7 kg (50 lb) over the preceding
6 months, which he attributed to a combination of diet and exercise.
On physical examination
The patient’s temperature was 36.1°„C (97°„F), with a heart rate of 80 beats per
minute and a blood pressure of 96/50 mm Hg; the oxygen saturation was 95%
while he was breathing ambient air.
The oropharyngeal examination was notable for poor dentition.
The lungs were clear on auscultation bilaterally.
The heart sounds were regular, with a normal S1, a physiologically split S2, and no
murmurs, rubs, or gallops.
The jugular venous pressure was 8 cm of water.
The abdomen was obese, soft, and nondistended, with normal bowel sounds and no
hepatosplenomegaly or masses.
The legs were markedly asymmetric, with 4+ pitting edema of the upper right
thigh& 2+ pitting edema of the left calf. The right leg&foot were dusky and cold, &
distal pulses were detectable only on Doppler ultrasonography.
On physical examination
On the right ankle and sole of the right foot, there were discrete hemorrhagic
bullae on a purpuric base with central, dusky discoloration
The bullae were confluent over the dorsomedial aspect of the foot and toes.
The entire right lower extremity was edematous but without eczematous change
There was no purpura other than that associated with the bullous lesions.
Pulses in the left leg were easily palpable, and there was no edema.
Muscle tone and strength and sensation of pinprick and light touch were intact
and equal in both legs.
Na136 mmol per liter, K 4.6 mmol per liter, chloride 110 mmol per liter,
bicarbonate 23 mmol per liter
BUN 62 ,cr 2.1 , glucose 114,1 month earlier, BUN 18 mg , cr 0.8
ALT 31 U, AST 34 ,TSB 0.5 ,SAP 630 ,albumin 3.1.
WBC 16,900,PCV 37.1%, platelet 283,000
A peripheral-blood smear was negative for schistocytes.
PT 42.3 seconds (INR, 4.3), PTT 89 seconds , fibrinogen 215 mg/ dl
An U/S of the right leg showed noncompressibility of the deep veins, consistent
with thrombosis, extending from common femoral vein to the popliteal vein.
IV VK administered, after INR decreased to 1.5.
IV UF heparin was initiated.
Leg venography revealed complete occlusion of the right common
femoral vein, femoral vein &popliteal vein.
After pulse-spray thrombectomy with a rheolytic catheter, a large
thrombus burden remained, prompting overnight catheter-directed
thrombolysis with tissue plasminogen activator (t-PA).
The following day, a repeat venogram showed restored patency of
the venous system .
The t-PA catheter was removed, and systemic anticoagulation
therapy was resumed.
Laboratory testing before the initiation of heparin therapy was
notable for a normal homocysteine level,normal results of an
antithrombin III functional assay & activated protein C resistance
Results of testing for the prothrombin G20210A mutation were
negative, and antiphospholipid antibodies were not detected.
The γ-GT 295 IU per liter (normal range, 0 to 40).
Computed tomography of the abdomen and pelvis without the IV
contrast showed multiple hypodense liver lesions, up to 3 cm in
diameter&extensive periportal/ gastrohepatic retroperitoneal
lymphadenopathy& diffuse omental nodularity & caking &
irregular, masslike thickening of the greater curvature of the
OGD/EUS revealed a large, infiltrative, & centrally ulcerated mass on the greater
curvature of the stomach.
Pathological exam revealed poorly differentiated, invasive adenocarcinoma.
Progressive hypotension&renal failure developed, both of which were
unresponsive to fluid resuscitation.
Treatment with IV dopamine / vasopressin was initiated.
The vascular-surgery service was consulted for consideration of right-leg
amputation, but the patient declined the procedure, given his poor overall
At his request, vasopressor therapy was withdrawn&comfort measures were
initiated; he died 10 days after admission.
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