Another patient pops up on the electronic medical record tracking board: a 52-year-old man with back pain who had run out of pain medication. A pink box indicates the lowest possible triage severity. A quick look at prior visits reveals that this diabetic, hypertensive smoker with high cholesterol was admitted for weakness and numbness of the right lower extremity just two months ago. His stroke workup, including head CT, brain MRI, and MRA, was normal. A lumbar MRI was also was relatively unremarkable.
With an empty bottle of Tramadol in his hand, the (fully dressed) patient recounted that the pain medicine initially seemed to help but didn't by the end. Perhaps, he said, he needed "something stronger." He also wondered if he was getting too old for his job because he and his coworkers race down the stairs at the end of the shifts. Now he has pain in his read end and down his legs. He just can't do it anymore.
A CT was ordered, almost inexplicably. Perhaps it was a slow night. Something really just didn't add up. Maybe a scan would give a clue.
The radiologist provided the diagnosis readily apparent by an impeccable exam: atherosclerosis obliterans of the aortoiliac vessels.
Embarrassingly, this patient had classic Leriche syndrome. Not only did he have four of the four risk factors — hypertension, diabetes, high cholesterol, and smoking — he also had the full triad of symptoms: claudication of the lower extremities, decreased lower extremity pulses, and impotence.
Yes, had someone asked, the patient would have quietly acknowledged "claudication a la troisieme member," as the French surgeon Rene Leriche described it more than a century ago. He also had, in fact, bilateral mid-abdominal bruits, bilateral femoral bruits, diminished femoral pulses, and barely palpable pedal pulses on retrospective physical exam. Certainly ABIs (ankle-brachial index) would have been markedly abnormal, had they been performed.
A few days later after stopping his metformin, the arteriogram revealed a pinpoint stenosis of the left common iliac artery with a complete or near-complete stenosis of the origin of the left internal iliac artery and a pinpoint stenosis of the mid-right common iliac artery with a patent internal iliac artery on that side.
After stent angioplasty of the left and right common, his pedal pulses and capillary refill returned to normal. Just as with Leriche's first published case, I expect that this patient again walks without pain and maintains an erection.
Tip to Remember: Always meticulously check the vascular status of the extremities when a patient has neurologic complaints.