The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Chana A. Sacks, M.D., Editor

Phlegmasia Cerulea Dolens

with Compartment Syndrome
A B

A
Hsin-Ti Lai, M.D. n 81-year-old man with hypertension presented to the emer-
Kaohsiung Medical University Hospital gency department with pain and swelling of the left thigh and lower leg
Kaohsiung, Taiwan that had developed during the previous several hours. He had no history of
recent surgery or trauma and no known personal or family history of clotting
Shu-Hung Huang, M.D., Ph.D.
disorders. The left lower leg was tender, cold, and swollen (Panel A), and the left
Kaohsiung Medical University dorsalis pedis pulse was not palpable. Computed tomography performed after the
Kaohsiung, Taiwan
huangsh63@gmail.com administration of contrast material showed partial thrombosis of the inferior vena
cava and complete thrombosis of the left common iliac, common femoral, super-
ficial femoral, and deep femoral veins. Anticoagulation with unfractionated heparin
was initiated, and emergency fasciotomy was performed to treat the acute com-
partment syndrome. The postoperative course was complicated by reperfusion
injury with shock and acute kidney injury. The patient underwent percutaneous
transluminal angioplasty and catheter-directed thrombolysis. Phlegmasia cerulea
dolens is a rare syndrome caused by acute, extensive venous thrombosis. Prompt
diagnosis is crucial for limb salvage and to minimize morbidity. The patient’s
condition improved (Panel B), and he recovered renal function. After 25 days of
hospitalization, he was discharged while receiving rivaroxaban. Subsequent evalu-
ation that included age-appropriate cancer screening did not reveal the cause of
this extensive clotting.
DOI: 10.1056/NEJMicm1704996
Copyright © 2018 Massachusetts Medical Society.

658 n engl j med 378;7 nejm.org February 15, 2018

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