Painful swollen leg - think beyond deep vein thrombosis or Baker's cyst

Login or register to view PDF.
Abstract

Background
The diagnosis of deep vein thrombosis of leg is very common in clinical practice. Not infrequently a range of pathologies are diagnosed after excluding a thrombosis, often after a period of anticoagulation.

Case presentation
This is a report of three patients who presented with a painful swollen leg and were initially treated as a deep vein thrombosis or a baker's cyst, but later diagnosed as a pleomorphic sarcoma, a malignant giant cell tumor of the muscle and a myxoid liposarcoma. A brief review of such similar reports and the relevant literature is presented.

Conclusion
A painful swollen leg is a common clinical scenario and though rare, tumors must be thought of without any delay, in a duplex negative, low risk deep vein thrombosis situation.

Pages

Background
Painful swollen leg is a common clinical scenario. Deep vein thrombosis (DVT) often presents as a painful swollen leg and prompt management is vital to prevent fatal pulmonary embolism. The common differential diagnoses include cellulitis and a ruptured baker's cyst 1. Rare pathologies with a similar clinical picture to venous thrombosis of calf 2 and dual pathologies have been reported 1,3 including tumors 4. Careful evaluation is needed to avoid inappropriate management and vitally a catastrophic delay in initiating appropriate treatment. We report three case histories of patients managed initially as a DVT of calf or a baker's cyst and later referred to our centre with a provisional diagnosis of a soft tissue tumor.

Case presentation
Case 1

A 70 year old female presented to general practitioner with complaints of pain in left knee and calf. Initial knee radiographs showed early osteoarthritis. As there was associated calf tenderness she was admitted for further investigations. All blood parameters were normal. D-dimers at the time of admission were 440 ng/ml. She was categorized as moderate risk for a DVT on clinical examination. Anticoagulation was initiated suspecting a DVT and the Duplex scan of the leg was inconclusive.

Pages

References

 

  1. Langsfield M, Matteson B, Johnson W, Wascher D, Goodnough J, Weinstein E: Baker's cyst mimicking the symptoms of deep vein thrombosis: Diagnosis with venous duplex scanning. J of Vascular Surgery 1977, 25:658-662.
  2. Maksimovic Z, Cvetkovic S, Markovic M, Perisic M, Colic M, Putnik S: Differential diagnosis of deep vein thrombosis. Srp Arh Celok Lek 2001, 129:13-17.
  3. Lewis D, Appleberg M: Unusual presentation of a rare venous tumour. ANZ J Surg 2004, 74:820-822.
  4. Buchbinder D, Mc Cullough GM, Melick CF: Patients evaluated for venous disease may have other pathological conditions contributing to symptomatology. Am J Surg 1993, 166:211-215.
  5. Kyrle PA, Eichinger S: Deep vein thrombosis. The Lancet 2005, 365:1163-1174.
  6. Scarvelis D, Wells PS: Diagnosis and treatment of deep vein thrombosis. CMAJ 2006, 175:1087-1092.
  7. Anderson DR, Kovacs MJ, Kovacs G, Stiell I, Mitchell M, Khoury V, Dryer J, Ward J, Wells PS: Combined use of clinical assessment and D-dimer to improve the management of patients presenting to the emergency department with suspected deep vein thrombosis (the EDITED study). J Thromb Haemost 2003, 1:645-651.
  8. Heim SW, Schetman JM, Siadaty MS, Phibrick JT: D-dimer testing for deep venous thrombosis: A metaanalysis. Clin Chem 2004, 50:1136-1147.
  9. Anderson DR, Wells PS, Stiell I, Macleod B, Simms M, Gray L, Robinson KS, Bormanis J, Mitchell M, Lewandowski B, Flowerdew G: Management of patients with suspected deep vein thrombosis in the emergency department: combining use of a clinical diagnosis model with D-dimer testing. J Emerg Med 2000, 19:225-230.
  10. Walsh K, Kelaher N, Long K, Cervi P: An algorithm for the investigation and management of patients with suspected deep venous thrombosis at a district general hospital. Postgrad Med J 2002, 78:742-745.
  11. Killewich LA, Bedford GR, Beach KW, Strandness DE Jr: Diagnosis of deep venous thrombosis. A prospective study comparing duplex scanning to contrast venography. Circulation 1989, 79:810-814.
  12. Miller N, Satin R, Tousignant L, Sheiner NM: A prospective study comparing duplex scan and venography for diagnosis of lower-extremity deep vein thrombosis. Cardiovasc Surg 1996, 4:505-508.
  13. Kim-Gavino CS, Vade A, Lim-Dunham J: Unusual appearance of a popliteal venous aneurysm in a 16 year old patient. J Ultrasound Med 2006, 25:1615-1618.
  14. Nakamura T, Tomoda K, Yamamura Y, Tsukano M, Honda I, Iyama K: Polyarteritis nodosa limited to calf muscles: a case report and review of the literature. Clin Rheumatol 2003, 22:149-153.
  15. Paul AS, Charalambous C, Maltby B, Whitehouse R: The management of soft tissue sarcomas of the extremities. Current Orthopedics 2003, 17:124-133.
  16. Braunstein EM, Silver TM, Martel W, Jaffe M: Ultrasonographic diagnosis of extremity masses. Skeletal Radiol 1981, 6:157-163.