2019 Research Forum

Applicant: Phillip Aguìñiga-Navarrete RA Principal Investigator & Principal Investigator: Rachel O’Donnell MD

Phlegmasia Cerulea Dolens from Pelvic Mass

Rachel O’Donnell MD, Vikram Shankar MD R3, Daniel Quesada MD, Kieron Barkataki DO Phillip Aguìñiga-Navarrete RA

INTRODUCTION PCD is associated with hypercoagulable states, stasis, vascular damage and genetics. Malignancy accounts for 20-40% of cases of PCD etiology.

PURPOSE A 53-year-old female with a history of a complex right-sided ovarian mass and aortic stenosis presented with right lower extremity (RLE) pain and swelling for 1 day. Physical exam revealed a swollen, cyanotic RLE (Image 1). Ultrasonography of the RLE revealed a thrombus, likely secondary to her ovarian mass. The patient was placed on heparin, underwent catheter-guided thrombectomy with TPA and was admitted to the ICU. The following day, the patient’s abdomen became distended and tender. CT of the abdomen demonstrated fluid collection around right ovarian mass (Images 2,3). Heparin was discontinued and 2 units of PRBCs and FFP were transfused. The ICU service determined the patient needed ovarian surgery. However, given the complex diagnoses requiring intervention from multiple services, the patient was transferred to a higher level of care facility where she underwent a successful balloon valvuloplasty. She was transferred back to our facility where she underwent debulking of her right ovarian mass, found to be a Sertoli-Leydig cell tumor. DISCUSSION While procoagulant properties of tumor cells is a contributing factor, our case demonstrates how malignancy can structurally impede blood flow with resulting deep venous thrombosis. Pain in PCD is usually sudden, severe and associated with swelling, cyanosis, or venous gangrene. Cyanosis is pathognomonic and can progress to compartment syndrome, circulatory collapse and shock. Without prompt aggressive treatment, patients may experience loss of limb or death. Anticoagulation with unfractionated heparin should be initiated. As demonstrated in this case, PCD can require multidisciplinary intervention, given its multifactorial etiology and risk for significant complications.

CONCLUSION This case demonstrates how PCD may be a complex entity arising from multiple etiologies and requiring a multidisciplinary team for intervention.

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