Online Clinical Case Study (January 2018)

Clinical Cardiology Series
臨床心臟科個案研究

The content of the January Cardiology Series is provided by:
Dr. TAN GuangMing
MBChB, MRCP, FHKCP, FHKAM (Med), Specialist in Cardiology
Dr. CHEUNG Shing Him, Gary
MBBS, MRCP, FHKCP, FHKAM (Med), Specialist in Cardiology
一月臨床心臟科個案研究之內容承蒙譚廣明醫生張誠謙醫生提供。

A patient with acute limb swelling

A 65-years-old male taxi driver with good past health presented with one-day onset of acute left lower limb swelling and pain. Figure 1 showed his both lower legs upon presentation. Clinical examination showed palpable 2+ femoral, popliteal and pedal pulses on both lower limbs.

1.

What is your diagnosis?
A. Acute limb ischemia
B. Critical limb ischemia
C. Phlegmasia Cerulea Dolens
D. Phlegmasia Alba Dolens
E. None of the above

  Back to top
   
2.

What imaging will you order?
A. Lower limb venous duplex ultrasound
B. lower limb arterial duplex ultrasound
C. MR Angiography of lower limb
D. XR lower limb
E. A and/or C

  Back to top
   
3.

What will be your initial treatment option?
A. Amputation
B. Unfractionated heparin
C. Leg elevation
D. Open fasciotomy
E. B & C

  Back to top
4.

What will be your next step of management?
A. Amputation
B. Open fasciotomy
C. Refer to Interventional Cardiology for endovascular thrombolysis
D. Systemic thrombolysis
E. Oral anticoagulation

  A, B
  Back to top
  Answer:
1 C, 2 E, 3 E, 4 C

Discussion:
This patient suffers from Phlegmasia Cerulea Dolens (PCD) which is a rare syndrome classically presented with a clinical triad of acute limb swelling, ischemic pain, and cyanosis. It is usually caused by massive venous thrombosis causing total or near-total venous occlusion. When venous return is impeded, intravascular hydrostatic pressure build up and fluid is extravasated into the interstitium. Subsequently, peripheral vascular resistance increases, reducing arterial inflow and resulting in acute limb ischemia. The goal of therapy is to immediately arrest thrombus formation while preserving the patency of the remaining venous collateral pathways. The initial management includes bed rest, elevation of the affected leg, fluid resuscitation and intravenous administration of heparin. If no clinical improvement occurs within 6-12 h of initiating heparin anticoagulation, then further invasive treatment should be considered. Catheter directed thrombolysis with or without mechanical thrombectomy has been shown to be a safe an effective treatment option. Prompt treatment is required to prevent the development of frank venous gangrene, which carries a high amputation and mortality risk.

Figure 3. Post venous intervention

Figure 4. 1 day after intervention

Reference:

  1. Erdoes LS, Ezell JB, Myers S, et al; Pharmacomechanical thrombolysis for phlegmasia cerulea dolens. Am Surg. 2011 Dec;77(12):1606-12
  2. Chinsakchai K, Ten Duis K, Moll FL, de Borst GJ. Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg. 2011 Jan;45(1):5-14.
  3. Chang G1, Yeh JJ. Fulminant phlegmasia cerulea dolens with concurrent cholangiocarcinoma and a lupus anticoagulant: a case report and review of the literature. Blood Coagul Fibrinolysis. 2014 Jul;25(5):507-11.
  4. Onuoha CU; Phlegmasia Cerulea Dolens: A Rare Clinical Presentation. Am J Med. 2015 Sep;128(9):e27-8.
  Back to top

Dermatology Series 皮膚科病例研究

Dermatology Series for January 2018 is provided by:
Dr. LEUNG Wai Yiu, Dr. TANG Yuk Ming, William, Dr. CHAN Hau Ngai, Kingsley, Dr. KWAN Chi Keung and Dr. CHANG Mee, Mimi
Specialists in Dermatology & Venereology
一月皮膚科個案研究之內容承蒙梁偉耀醫生鄧旭明醫生陳厚毅醫生關志強醫生張苗醫生提供。

A Six-year-old child with multiple itchy papule on his trunk

A six-year-old child presented with six months history of progressive papules on his trunk. Similar lesions were found in his elder brother two months ago. It raised his parent's concern for growing itchiness and pain. On examination, there were multiple pearly papules of 1mm to 3mm on his trunk, and dome shape umbilicus appeared in some individual lesion. No other skin manifestations were found.

Answers

1. What is the clinical diagnosis?
A. Molluscum contagiosum
B. Milia
C.Verrucae
D. Skin tags
  A
 

Back to top

 

2. These lesions is not contagious. (T/F)
False
Molluscum contagiosum is contagious and caused by pox DNA virus with an incubation period of two weeks or longer. Children are commonly affected and usually become more serious in those with atopic eczema or immune deficiency.
 

Back to top

 

3. How are they transmitted?
A. Direct skin contact
B. Autoinoculation
C. Sexual contact
D. All of the above
D
Molluscum contagiosum is usually transmitted through skin contact and autoinoculation, and it could be a sexually transmitted infection for adults. The spread of Molluscum contagiosum is also believed to be enhanced by warm and moist environment and therefore affected children are advised not to bathe or swim together with others.
 

Back to top

 

4. All of the following findings are compatible with the above clinical diagnosis EXCEPT
A. Involvement of sole and palm
B. Involvement of genitalia
C. May regress spontaneously in months
D. Systemic involvement does not occur
A
Molluscum contagiosum is usually self-limited and commonly resolves within three to four months for immunocompetent patients. It could affect any part of the body except the soles and palms. Genital involvement is more common in adults due to sexual contact.
 

Back to top

 

5. What are the treatment options?
A. Topical treatment such as tretinoin cream and trichloracetic acid
B. Physical treatment including curettage, cryotherapy and CO2 laser
C. Reassurance
D. All of the above
  D
Molluscum infection is usually self-limited in months and therefore no specific treatment is required in most of the cases. However, treatment is advised for enlarging or spreading lesions and the treatment plan should be individualized for each family due to different psychological burden of the children and parents. Topical treatment options include topical tretinoin and trichloroacetic acid. Curettage, cryotherapy and CO2 laser may be considered in recalcitrant cases.
  Back to top

Back to Online Clinical Case Study