Left Thigh Swelling Research Articles

Case Report: An Elusive Case of Septic Arthritis

Septic arthritis is a serious inflammatory infectious state of the joint secondary to microbial infection. In the pediatric population the most common route of infection is haematogenous spread. Less than fifty percent of patients with septic arthritis will yield positive culture results with a mortality rate of up to 42% in some cases. Due to the challenge in obtaining culture and identification of the causative organism the management of septic arthritis has been more of empirical in nature with the chosen antibiotic synchronized with the epidemiological data. Here is a case of a 14 months old female patient presenting at our hospital with a left knee and lower thigh swelling for three days with failure to bare weight on the limb. In addition, she had fever and diarrhea for three days. Upon evaluation clinical, laboratory and radiological findings supported septic arthritis expect for her blood, pus and synovial fluid culture of which all came back negative. She had poor response to intravenous ceftriaxone, gentamycin, metronidazole, ampicillin- cloxacillin and amoxicillin clavunate. Over the course of therapy, she developed septic shock, severe anemia and acute liver failure and was admitted to the intensive care unit. Afterwards she was initiated vancomycin and developed a hypersensitivity reaction with generalized edema which prompted cessation of the drug. Due to her critical state and poor response a triple therapy regimen composing of meropenem, ciprofloxacin and metronidazole was selected and maintained for three weeks followed by an oral clindamycin course for another three weeks of which she responded. In addition, surgical debridement arthrotomy, irrigation and drainage were done. Physiotherapy for rehabilitation is ongoing with patient recovering well.

Neglected fracture shaft femur presenting with pseudoaneurysm: a case report

A pseudoaneurysm is a collection of blood leaking from a damaged arterial wall. Development of the false aneurysm is due to either initial injury of the vessel or is a complication of internal fixation of the femoral fracture. Femoral artery pseudoaneurysms (FAPs) may close spontaneously if the tear is small enough to allow for clotting and sealing. On the other hand, rupture of the aneurysm can trigger thrombosis, distal embolization and compression of adjacent structures. We present a case of left superficial femoral arterial pseudoaneurysm in a 36-year-old male with fracture of left femoral shaft. A 36-year-old male with history of road traffic accident presented to our institute with pain and swelling in left thigh. Patient was investigated and diagnosed with fracture left femoral shaft with a pseudoaneurysm of the left superficial femoral artery (SFA). Stenting was done for SFA followed by open reduction and internal fixation of the femoral shaft fracture. Such cases require multidisciplinary approach and a proper planning with involvement of different medical specialities to achieve optimal results and to minimise any intraoperative and post operative complications.

Protein S Deficiency with Favourable Foetomaternal Outcome: A Case Report

Protein S is a multifunctional plasma protein, whose deficiency,results in a rare congenital thrombophilia, inherited in an autosomal dominant pattern. It can aggravate the hypercoagulable state of pregnancy, when it presents in parallel with the condition, leading to adverse maternal outcomes and foetal loss. A 35-year-old female third gravida having previous 2 deliveries by Lower Segment Caesarean Section (LSCS) presented to emergency at 10 weeks pregnancy with chief complaints of pain and swelling in left thigh since 4-5 days. After thorough investigations and work-up, the patient was diagnosed with Protein S deficiency. She was managed conservatively and was delivered by elective LSCS with bilateral tubal ligation at 38 weeks of gestation with good foetal and maternal outcomes.The rarity of Protein S deficiency along with the successful outcome of the pregnancy makes this a unique case.

Role of multimodality imaging for primary bone tumors among children: a case report

ABSTRACT Background: Bone lesions in children are very common and can be benign or malignant. Benign bone lesions, fortunately, are more common as compared to rare malignant neoplasms of bone. Osteosarcoma and Ewing sarcoma are the most common malignant bone tumors in younger age group. Multimodality imaging plays a major role in bridging the gap between clinical diagnosis and final diagnosis Case Presentation: We present here a case of 8-year-old male patient complained of progressive soft tissue swelling and pain in left thigh from 25-30 days. His X-ray of left femur showed a mixed density, predominantly sclerotic lesion involving mid-diaphysis. His contrast enhanced MRI of left thigh showed large, ill-defined, abnormal signal intensity medullary lesion seen in left femur involving mid to lower diaphyseal shaft, extending to metaphyseal region. His 99mTc MDP bone scintigraphy was done showing abnormal radiotracer uptake in lower half of left femur and adjoining soft tissue. Conclusion: Single modality imaging may not be enough in predicting the true extent of bone pathologies. Multimodality imaging plays a major role in characterizing the lesions to differentiate benign from malignant and bridging the gap between clinical diagnosis and final diagnosis. Keywords: Osteosarcoma, Ewing sarcoma, 99mTc MDP bone scintigraphy, case report

Spontaneous tensor fascia lata abscess caused by Parvimonas micra presenting as lateral hip pain.

Dear Editor, Parvimonas micra is a gram-positive obligate anaerobic bacterial species and known flora of the human oral cavity, respiratory system, gastrointestinal tract, and the female genitourinary tract.[1,2] It was originally identified in 1933 as Peptostreptococcus micros, underwent a reclassification in 1999 to Micromonas micros and ultimately was reclassified as P. micra in 2006.[1,3]Parvimonas micra has been implemented as an infectious organism in case reports of spondylodiscitis, vertebral osteomyelitis, iliopsoas abscess, hepatic abscess, endocarditis, empyema, meningitis, brain abscess and septic arthritis.[1–3] Although multiple areas of infection by P. micra have been described, tensor fascia lata infection has not been described.[4] A patient with no significant past medical history presented to our outpatient multidisciplinary pain center complaining of left hip pain. He was seen in the emergency department the day prior. X-ray of the hip was performed which did not reveal any acute pathology. His pain had been present for one week and had been worsening in intensity. He did not describe any radiation of the pain to the lower legs and denied any recent trauma to the area. He described swelling and fullness of the hip worsened with movement and relieved by rest. His physical examination was only positive for tenderness of palpation over the left greater trochanter. Due to a presumed diagnosis of greater trochanteric bursitis, conservative measures were pursued. He was prescribed naproxen 500 mg twice a day as needed, tizanidine 2 mg three times per day as needed, topical EMLA to the painful area. He was also instructed to start physical therapy and was provided a referral for the same. He was discharged from the emergency department after this visit. Nearly two weeks later, the patient presented to the emergency department with left thigh erythema and swelling. His laboratory work was significant for ESR of 115 and CRP of 16, white counts were 8.2. On exam, in the ED, he was afebrile and physical exam was positive for erythema, tenderness to palpation over the left thigh. Several pustules overlying the area along with areas of induration and fluctuance were noted. A CT with contrast of the left hip was performed which demonstrated a 20 × 10 × 6.5 cm rim enhancing fluid collection in the proximal lateral left thigh/gluteal region abutting and extending along the fascia lata of the thigh, dissecting into the substance of the tensor fasciae lata muscle and extending into the deep subcutaneous tissues [Figure 1]. The patient was started on broad-spectrum IV antibiotics and scheduled for incision and drainage in the operating room by general surgery. Drains were placed and the wound closed by secondary intention. Cultures from the operating room (anaerobic- tissue and abscess) yielded P. micra. Repeat blood cultures were negative at 5 days. The patient was kept on vancomycin and piperacillin/tazobactam for 3 days and transitioned to oral trimethoprim and sulfamethoxazole at discharge.Figure 1: Coronal view of left thigh CT demonstrating abscessThis case represents an unusual occurrence of P. micra abscess requiring prompt recognition of the abscess and prudent microbial identification. Financial support and sponsorship Nil. Conflicts of interest Dr. Shaparin reports the following disclosures outside the submitted manuscript; he was a consultant for Averitas Pharma and AcelRx Pharmaceuticals and has received research grant funding from Grunenthal and Heron Therapeutics. Dr. Koushik has served as a consultant for AcelRx Pharmaceuticals.

De-differentiated giant thigh liposarcoma disguised as recurrent lipoma; a case report

Introduction and importanceLipomas are one of the commonest soft tissue tumors which usually arise from subcutaneous plane. Lipomas can progress to one of the three types of liposarcomas. Dedifferentiated liposarcomas have metastasis potential, risk of recurrence and increased risk of mortality. The culture of taking every lipoma as benign should be seriously considered with different approaches as it can lead to sarcomatous degeneration in some cases.Case presentationA 78 years old male patient present to our hospital with recurrent left thigh swelling of two years duration with limping and sense of heaviness on left side. He has history of previous surgery for the same complaint on the same site two times, six and four years ago. Histological diagnosis in both cases was lipoma. Objectively he has 20 × 60 cm non tender, soft to firm, slightly mobile swelling on left thigh spanning anterior, lateral and posterior compartment but no inguinal swelling. Fine needle aspiration cytology from the mass reported sarcoma. CT-scan stated diagnosis as sarcomatous tumor.Clinical discussionLipoma is commonest soft tissue tumor arising from adipocytes more often in young adults, women and overweight population. Well-differentiated liposarcoma can progress to dedifferentiated liposarcoma over time which is slightly aggressive than its precursor. Management of liposarcoma depends on stage, site and histology. Surgical resection with radiotherapy is the standard of care for localized dedifferentiated liposarcomas.ConclusionIt is difficult to differentiate between giant lipoma and well-differentiated liposarcoma with physical examination and imaging. Histopathologic examination in uncertain conditions will decrease morbidity and mortality from the more aggressive forms of liposarcomas.

Man With Left Thigh Swelling and Pain

Man With Left Thigh Swelling and Pain

Case 289

History An 8-year-old girl presented to our hospital with painful swelling of the left thigh and soft-tissue swelling in the right chest wall. The patient's history revealed that the swelling had been present since birth but had grown slowly. She had no history of relevant trauma. Her blood pressure was 145/95 mmHg (normal value, <115/76 mmHg), and her heart rate was 105 beats per minute (normal value, 75-118 beats per minute). The patient's electrocardiogram displayed sinus tachycardia. Physical examination revealed soft-tissue hypertrophy in the left thigh and right lower chest wall. A painful soft and flexible mass measuring approximately 5 × 6 × 15 cm (in the anteroposterior, transverse, and craniocaudal directions, respectively) was detected at the left thigh. Moreover, a painless soft mass measuring approximately 3 × 8 × 10 cm (in the anteroposterior, transverse, and craniocaudal directions, respectively) was detected in the right lower chest wall, and the overlying skin was intact. Pink macules with a 3-cm diameter on the anterior left superior thigh and a 2.5-cm diameter in the left inguinal region were detected. Examination of other systems, including the cardiovascular system, revealed normal findings. Laboratory test results were within normal limits. Abdominal US showed perirenal vascular collaterals, and musculoskeletal US of the left thigh revealed vascular collaterals (images not shown). Therefore, thoracoabdominal CT angiography (Fig 1a-1c) and contrast material-enhanced MRI of the bilateral thigh (Fig 2a-2c) were performed.

Mesenchymal Chondrosarcoma: A Rare Aggressive Variant of Chondrosarcoma

A 15-year-old boy reported a 2-month history of severe left thigh pain Physical examination revealed left thigh swelling measuring 6x5 cm. X-ray of the region showed mixed lytic and sclerotic lesion involving the femoral head and neck. A Computed Tomography scan showed mixed lytic and sclerotic lesion involving the femoral head and neck with cortical irregularity and mild periosteal reaction with associated soft tissue in the anterior aspect. Magnetic resonance imaging demonstrated heterogeneous signal intensity lesion with areas of sclerosis involving the femoral head and neck. The large associated soft tissue in the anterior aspect appears predominantly hyperintense on T2W images. On post-contrast axial and sagittal images, heterogeneous enhancement with areas of necrosis involving soft tissue was seen. A presumptive radiological differential diagnosis of Ewing Sarcoma and Osteosarcoma was made. However, on histopathology, it was a case of mesenchymal chondrosarcoma.

MON-347 Osteitis Fibrosa Cystica and Pathological Fractures: The Classic but Neglected Skeletal Manifestation of Primary Hyperparathyroidism

Background: Osteitis fibrosa cystica is one of the classic manifestations of primary hyperparathyroidism (PHPT), yet it has become increasingly rare due to early detection of PHPT. Clinical case: A 37-year-old woman was referred to our hospital for fixation of multiple fractures. Before transferring to our hospital, she was admitted to a local hospital due to right distal humerus and left tibial fractures without history of trauma. During the hospitalization, a new fracture at left femur had occurred. Her past medical history was significant for fractures of right shoulder, left elbow and right femur when she fell on the ground 5 years ago and treated by fixation. She had a history of kidney stones in the remote past. She denied family history of calcium or skeletal disorders.Clinical examination revealed gross deformities at right elbow, left thigh and painful swelling of the left tibia. On HEENT examination, there were no palpable neck masses.Upon review of plain radiographs from outside hospital, we found not only fractures but diffuse osteopenia and brown tumors at multiple sites including shaft of right humerus, right proximal radius, left proximal femoral shaft and left tibia. Skull X-ray showed salt-and-pepper appearance. There were prominent subendplate densities at multiple lumbar spines (Rugger-jersey spine). These findings were consistent with osteitis fibrosa cystica which prompted further laboratory investigation for PHPT. The patient had a high corrected serum calcium level of 13.6 (8.6-10.0) mg/dl, low serum phosphate of 2.2 (2.5-4.5) mg/dL, serum creatinine of 1.16 (0.51-0.95) mg/dL, glomerular filtration rate (GFR) of 60.29 ml/min, high serum alkaline phosphatase of 1,482 (35-105) U/L. The serum parathyroid hormone (PTH) level was significantly high at 3,850 (15-65) pg/mL. Vitamin D level was low at 5.98 (≥30) ng/mL.The patient was diagnosed with PHPT. The left lower parathyroid adenoma was identified by 99mTc-Sestamibi scan with single photon emission computed tomography and neck ultrasound. Given severe skeletal manifestations and extremely elevated PTH level, urgent parathyroidectomy was performed. A 2.5-cm parathyroid adenoma was removed which was histologically confirmed by a pathologist. Postoperatively, she developed a hungry bone syndrome which resolved 10 months after. Clinical lesson: In current practice, skeletal manifestation of PHPT is uncommon with a reported incidence of 1.4% in US. Osteitis fibrosa cystica is a radiographic feature of PHPT characterized by demineralized skeleton, salt-and-pepper appearance of the skull, subperiosteal resorption of the phalanges, bone cysts, and brown tumors. Although PHPT has evolved to asymptomatic disease in majority of patients, the classic skeletal involvement should not be overlooked, particularly in young patients who present with multiple pathological fractures.

Hydatid Disease of The Bone

Hydatid disease of the bone is a very rare condition. It represents about 0.5–4% of all human hydatid disease. Spine is the most affected part of the skeleton (50% cases). Extra-spinal bone hydatidosis is much rare. A 20 year old woman presented with severe pain and swelling in left thigh. On examination, there was a boggy swelling in left thigh suggestive of abscess. MRI of left hip joint and thigh revealed features of osteomyelitis with pathological fracture in upper shaft along with multiloculated collections in upper thigh muscle. Biopsy revealed evidence of Hydatid cyst. Hydatid disease of the bone is a rare manifestation of Echinococcosis. It is hence important to consider the possibility of Hydatid disease of the bone as a differential diagnosis of lucent lesions of bone especially in areas where it is prevalent for proper treatment of the patient. Radiological, laboratory, and clinical findings combined with strong element of suspicion are the key for diagnosis.

PULMONARY CAVITARY LESION WITH RARE PSEUDOMONAS STUTZERI

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Pseudomonas stutzeri is a gram-negative rod bacterium infrequently associated with clinical infection. We present a case of pulmonary cavitary lesions caused by P.stutzeri. CASE PRESENTATION: A 59-year-old male with history significant for intravenous (IV) heroin abuse (last use 1 week prior), splenectomy and culture negative endocarditis (10 months prior) presented to the hospital with 1 week of chest pain, dyspnea and subjective fevers. Within a few hours of admission, a rapid response was called for altered mental status, chest pain and tachypnea. Computed tomography of the chest revealed a 12cm cavitary left lower lung lesion. He was placed on tuberculosis precautions and subsequently transferred to the Intensive Care Unit (ICU) for further management. Blood cultures were obtained prior to empiric vancomycin plus piperacillin/tazobactam. He required intubation for impending respiratory failure. Bronchoscopy with bronchoalveolar lavage (BAL) was performed demonstrating copious mucus and purulent secretions bilaterally. Approximately 36 hours into his admission, he suffered a PEA (pulseless electrical activity) arrest. Return of spontaneous circulation (ROSC) was achieved after 15 minutes of cardiopulmonary resuscitation (CPR). Physical exam revealed diffuse crepitus, subcutaneous emphysema tracking along posterior thorax extending into left lateral thigh and profound scrotal swelling. Arterial blood gas demonstrated acidemia with hypercarbia. Within less than an hour, he suffered a second PEA arrest. There was concern for ruptured pleural cavitary lesion leading to a tension pneumothorax. Needle decompression performed bilaterally was unsuccessful; surgery at bedside placed left hemithorax chest tube. Again, achieved ROSC after 18 minutes of CPR. Unfortunately, within a few minutes he decompensated into ventricular fibrillation. Further resuscitation efforts a third time were unsuccessful. Post-mortem blood cultures were negative but his BAL cultures were positive for pan-sensitive Pseudomonas stutzeri. All acid-fast bacilli smears and cultures were negative. DISCUSSION: Pseudomonas stutzeri has rarely been reported as a cause of necrotizing pneumonia (1) and may represent only 1% of all clinical Pseudomonas isolates (2). In our patient, the timeline of events, whether the cavitary lesion ruptured from the positive pressure of mechanical ventilation or as a consequence of CPR remains a mystery. CONCLUSIONS: There is debate in the literature regarding the pathogenicity of this organism which is frequently deemed to be colonization rather than pathogenic. However, in the case of this patient, all other infectious work up was negative and no alternative pathogen could be linked to the development of the cavitary lesions. This case emphasizes the necessity of diagnostic testing to identify uncommon pathogens. Reference #1: Lin KH et al, Pseudomonas stutzeri necrotizing pneumonia in pre-existing pulmonary tuberculosis. Intern Med. 2014;53(21):2543-6. 2014 Nov 1. Reference #2: Bisharat, N et al, 10-Years Hospital Experience in Pseudomonas stutzeri and Literature Review. The Open Infectious Diseases Journal, 2012, 6, 21-24. DOI: 10.2174/1874279301206010021 DISCLOSURES: No relevant relationships by Zachary Bugos, source=Web Response No relevant relationships by Brandon Smith, source=Web Response

Myositis ossificans with hoffa’s disease (Lipoma Arborescens): Usual mimicker of soft tissue sarcoma

Myositis Ossificans is a benign heterotopic ossification mainly occurs in muscles and soft tissue. Hoffa’s disease (Lipoma Arborescens) is a rare benign lesion characterized by villous lipomatous proliferation of synovial membrane. Due to its unusual property of abnormal ossification in muscles and soft tissue, myositis ossificans presents a diagnostic and therapeutic problem to pathologist and clinician respectively, as it mimics soft tissue sarcoma. We present a case of 14 year male presented with left thigh swelling near knee joint with restricted movements. Clinically it was suspected as synovial sarcoma. Wide local excision of mass and synovial membrane excision was done. Final diagnosis on histopathology was given as Myositis Ossificans with Hoffa’s disease. The aim of this case is to highlight the unusual combination as myositis ossificans with lipoma arborescens together due to its rarity and sarcoma mimics. Such type of combination was reported for the first time in present literature in Indian context. Keywords: Myositis ossificans, Hoffa’s disease, Lipoma arborescens, Synovial sarcoma, Tumor, Mimics.

Morel-Lavallée lesion in a ‘non-traumatic’ thigh: a diagnostic challenge!

Background: Morel-Lavallée Lesion (MLL) or Morel-Lavallée Seroma (MLS) is a posttraumatic seroma that occurs following a closed degloving injury. It is very important for trauma surgeons to be aware of this relatively rarely reported entity as early diagnosis increases the likelihood of successful management.&#x0D; Case report: We present a patient, wherein the patient had no history of trivial trauma and presented with a gradually growing swelling of left thigh, that was clinically and radiologically diagnosed as a soft tissue neoplasm, successfully managed by surgical excision and were reported to be a MLS. The clinical diagnostic dilemma was solved by the histopathologist!&#x0D; Conclusion: A differential diagnosis of MLL should be kept in mind in patients presenting with soft tissue swellings.&#x0D; Bangladesh Journal of Medical Science Vol.18(1) 2019 p.145-148

Acute Iliac Vein Thrombosis Secondary to Exacerbation of May-Thurner Syndrome by Overriding Arterial Crossover Sheath

A 69-year-old man presented with acute left thigh pain and swelling 1 day after successful left superficial femoral artery balloon angioplasty and stenting for claudication via contralateral right common femoral artery access with a 45-cm 6-F crossover sheath. Physical examination revealed palpable

Sciatic neuropathy caused by an intermuscular lipoma in dogs

Lipomas are common, usually slow-growing, benign tumours of mesenchymal origin that most commonly occur on the proximal limb and trunk of middle-aged to older dogs. They are rarely associated with either local invasion or malignancy, unlike infiltrative lipomas and liposarcomas, respectively. Three dogs, a 10-year-old mixed-breed female of 35 kg body weight, a 10-year-old mixed-breed male of 30 kg body weight, and an 11-year old female German shepherd of 38 kg body weight, were presented with a 3–6 month (median, 5 months) history of progressive left pelvic limb lameness and thigh swelling. A lesion affecting the soft tissue of the thigh and the left sciatic nerve was suspected in all dogs. A left thigh magnetic resonance (MR) revealed a homogenous, well circumscribed tumour in the mixed-breed dogs and two similar tumours in the German shepherd. The tumours were interposed between the semimembranosus and semitendinosus muscles. The treatment involved surgical extirpation of the tumours. A follow-up examination 12 months post operation showed mild lameness and proprioceptive deficits in the operated limb in all the dogs. The withdrawal reflex and the cranial tibial reflex were normal. Neither mass nor thickening were palpable in the thigh region. Although intermuscular lipoma is rare, it should be suspected in dogs with progressive monoparesis. Magnetic resonance is a valuable imaging method for diagnostic precision and pre-operative planning. Quick diagnosis and decompressive surgery are required to allow recovery.

Chronic myeloid leukemia with soft tissue infiltration: a case report

A 27 year old male patient with chronic myeloid leukemia under irregular hydroxyurea treatment presented with a left thigh swelling associated with a dull aching pain. Blood examination revealed a total leukocyte count [TLC] of 125,000/mm3 with 13% metamyelocytes, 8% myelocytes, 1% promyelocytes and 3% band cells. A fine needle aspiration biopsy of the swelling revealed mostly myeloblasts with occasional promyelocytes. He was maintained on tablet hydroxyurea 2g given in divided daily doses along with allopurinol, systemic alkaliser and plenty of oral fluids. Gradual symptomatic relief was achieved over next 2 months with no palpable lump after 3.5 months. TLC was 38,400/mm3 with 1% promyelocytes and myeloblasts and 5% band form. There was reduction in the liver size during this period but no reduction in spleen size. He is currently being maintained on hydroxyurea 2g with other supportive care and has not had any recurrence of symptoms for the last 9 months.

Rapid bedside diagnosis of pyomyositis with ultrasound-guided needle aspiration

A 62-year-old male with a past medical history of cirrhosis presented to the emergency department with left thigh pain and swelling 2 weeks after trauma to the left lower extremity due to a ground level fall. On arrival, physical exam revealed significant edema, erythema and warmth of the left thigh concerning for infection. Point-of-care soft tissue ultrasound by the emergency physician revealed multiple complex fluid collections deep within the quadriceps muscle. Ultrasoundguided needle aspiration of these fluid collections was performed at the bedside while waiting for surgical consultation and MRI. Copious amounts of purulent fluid were aspirated prompting the early diagnosis of pyomyositis. Therapeutic management was expedited as a result of these findings. Point-of-care ultrasound is a valuable tool for the early and rapid detection of pyomyositis and can expedite definitive treatment.

Embolization of iliofemoral thrombus during diagnostic venography.

A 34-year-old woman presented with acute left thigh and calf swelling, cyanosis, and pain, consistent with phlegmasia cerulea dolens. Duplex ultrasound demonstrated extensive left acute iliofemoral deep venous thrombosis. She was heparinized and taken urgently for interventional treatment. The right common femoral vein was accessed to place a prophylactic inferior vena cava (IVC) filter. The IVC venogram demonstrated laminated thrombus in the IVC causing a ∼50% reduction in lumen, extending to the renal veins.

Incidental Finding of Traumatic Arteriovenous Fistula in the Tibial Peroneal Trunk during Venous Duplex Ultrasound to Rule Out Deep Vein Thrombosis

Traumatic arteriovenous (AV) fistulas are caused by injury to an adjacent artery and vein and can be potentially limb threatening. AV fistulas occurring at the level of the popliteal artery result in a 10% greater rate of amputation than those at the level of the common femoral artery. Clinical findings of AV fistula in the lower extremity are similar to that of deep vein thrombosis and include pain, swelling, and redness of the extremity. This case study demonstrates how a routine lower-extremity venous Duplex ultrasound led to the diagnosis of a traumatic AV fistula that required surgical repair. The patient presented to the emergency department with a cold foot and was found to have a thrombosed left iliac artery and femoral artery system. A thrombectomy catheter was used to remove the clot from the superficial femoral, above knee popliteal, and posterior tibial arteries. One week postoperatively, the patient had continued left thigh and calf pain and swelling; a lower-extremity venous ultrasound was ordered to rule out deep-vein thrombosis. Findings of the Duplex ultrasound were negative for deep-vein thrombosis; however, Doppler imaging revealed abnormal flow in both the venous and arterial systems of the left femoral and popliteal vessels. Venous flow was found to be continuous and turbulent. The arterial system had low resistance, marked spectral broadening, and high velocity. Normal venous flow is spontaneous, phasic, and pulsatile with respiration. Normal arterial flow in the lower extremities is high resistance and triphasic. Traumatic AV fistula was suspected in the tibial peroneal region, and confirmed with computed tomography angiography. The patient underwent surgical repair of fistula with vein graft.