2019 Research Forum

Vikram Shankar 1 MD R3, Rachel O’Donnell 2 MD, Daniel Quesada 2 MD, Kieron Barkataki 2 DO, Phillip Aguìñiga-Navarrete 3 RA Phlegmasia Cerulea Dolens from Pelvic Mass

1 PGY-III, Emergency Medicine, Kern Medical, Bakersfield, CA 2 UCLA Health Sciences Clinical Instructor, Emergency Medicine, Kern Medical, Bakersfield, CA 3 Research Coordinator, Emergency Medicine, Kern Medical, Bakersfield, CA

Case Presentation 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.

Image 2

Axial computed tomography displaying a 15 x 10 x 11 centimeter ovarian mass.

Discussion Phlegmasia Cerulea Dolens (PCD) is associated with hypercoagulable states, stasis, vascular damage and genetics. Malignancy accounts for 20-40% of cases of PCD etiology. 1 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.

Diffusely tender cyanotic and edematous right leg with palpable pulses. Image 1

Image 3 Computed tomography displaying an ovarian mass in the right lower quadrant, obstructing the inferior vena cava.

References

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3. Brockman SK and Vasko JS. Phlegmasia cerulea dolens. Surg Gynecol Obstet . 1965 Dec;121(6):1347-56.