American Journal of Physical Medicine & Rehabilitation:
From the Department of Physical Medicine and Rehabilitation, William Beaumont Hospital, Royal Oak, Michigan.
All correspondence and requests for reprints should be addressed to John T. Maltese, MD, Department of Physical Medicine and Rehabilitation, William Beaumont Hospital, Royal Oak, MI 48073.
Physiatric practices, which regularly act as consultants to the emergency center, often encounter challenging pain and weakness diagnostic problems.1 Although most eventually prove to be relatively routine neuromusculoskeletal diagnoses, on occasion other organ systems may be the actual source of symptoms, including among others vascular or visceral pathology, that is, splenic ruptures, kidney, and gallbladder lithiasis.
In the urgent triage-oriented environment of the emergency center, although imaging technology is now readily available, at the bedside a thorough history and physical examination still remain essential to a discriminating differential diagnosis. When pain is the pre-eminent complaint, its intensity, anatomical distribution, temporal history, and relation to activity levels are all critical factors in achieving an accurate diagnosis.
A 50-yr-old man presented to an acute general hospital emergency center after a near syncopal episode. He complained of severe left groin “pressure” with pain radiation into the thigh during ambulation. The discomfort was so severe that he had a syncopal episode, lost his balance, and fell. He also complained of intermittent low-back pain. He denied joint swelling and joint erythema in either of the lower limbs and a previous history of circulatory problems. A computed tomographic scan of the abdomen and pelvis was reported to be normal. The neuromusculoskeletal examination was unremarkable as was the vascular examination of the limb. There was no evidence of an inguinal hernia. His gait pattern was initially stable; however, after walking 15–20 feet, he increasingly complained of severe groin “pressure” with pain radiation to the left medial thigh.
Magnetic resonance imaging of the lumbar spine demonstrated degenerative vertebral disc disease and evidence of bilateral iliac vein distention, suggesting the presence of a thrombosis (Fig. 1). Later, duplex imaging with color and spectral Doppler confirmed the presence of extensive bilateral iliofemoral thrombosis. A subsequent computed tomographic scan of the chest revealed the presence of multiple pulmonary emboli. An inferior vena cava filter was inserted, and a thrombolysis was successfully completed.
In its late stages, iliofemoral venous thrombosis can readily be recognized by the clinical signs of “phlegmasia cerulea dolens.”2 This syndrome features limb pain, swelling, and cyanosis as the once local clot propagates distally throughout the deep and superficial venous “tree.” Approximately 2%–10% of these patients will progress to this critical stage requiring emergent surgery.3 Early diagnosis is essential to initiating anticoagulant therapy while the clot is confined only to the iliac and femoral veins.4 The presence of a hypercoagable state, an occult malignancy, and an obstruction to venous return will accelerate the distal clot formation and increase the risk of pulmonary emboli. Retrospectively, the pain description in this patient was that of an ischemic claudication aggravated by ambulation and relieved by sitting. However, there were no overt clinical signs of vascular compromise in the lower limbs. The neuromuscular examination was also normal, the eventual diagnosis further confounded by a remote history of low-back pain. Historically, vascular and neurogenic claudication can mimic one another. In this particular case, spinal stenosis and iliofemoral thrombosis had been considered in the differential diagnosis. Fortunately, it was initially recognized on a lumbar spinal magnetic resonance imaging to be subsequently confirmed by duplex Doppler imaging. As in many challenging diagnostic situations, astute clinicians must remember to “think outside the box” by always being open to a diagnosis not necessarily in their particular area of expertise. As this case demonstrates, an accurate history is the first step in this regard.
1. Brennan MJ, LaBan MM: The physical medicine consultant in the emergency center: New challenges, new horizons. Arch Phys Med Rehabil
2. Menon J, Salman MM, Hamilton G: Venous thrombolysis. Curr Treatment Options Cardiovasc Med
3. Saarinen J, Anturaniemi M, Heikkinen M, et al: Clinical and anatomical findings of acute iliofemoral deep venous thrombosis. Phlebology
4. Sharma GV: Long-term benefit of thrombolytic therapy in patients with pulmonary embolism. Vasc Med