Phlegmasia cerulea dolens in a case of metastatic prostate cancer
Shih-Ting Chiu, Kuo-How Huang
Department of Urology, National Taiwan University Hospital
Phlegmasia cerulea dolens (PCD, painful blue leg) is an uncommon form of extensive deep vein thrombosis in drainage system in pelvis or limbs. The symptoms are characterized with acute edema, pain and violaceous discoloration of the affected limb. Further complications include gangrene, compartment syndrome, pulmonary embolism, shock and death. Thus, PCD warrants more aggressive treatment if diagnosed. Here we presented a case with metastatic prostate cancer and PCD.
Our case is an 85-year-old man had underlying disease of prostate cancer, hypertension, diabetes mellitus, chronic deep vein thrombosis, peripheral arterial occlusive disease and bilateral hydronephrosis secondary to prostate cancer. He had been diagnosed with prostate cancer for 3 years, iPSA 33, Gleason score 4+4, with bladder neck invasion and pubic bone metastasis, and received regular androgen deprivation therapy with leuprorelin as well as enzalutamide. He presented with acute onset pain and edema in right root and cyanosis in toes. The dorsalis pedis pulsation was weak but present, and the foot was still warm. His vital signs were within normal limits. Laboratory test showed normal white blood cell count (7.9K/uL) and normal coagulation test but elevated D-dimer level (12.67 ug/mL, cut-off <0.5 ug/mL). Blood culture was negative. The affected area progressed within days, with cyanosis in the distal one-third of the foot and erythema from foot to calf. Vascular ultrasound found patent flow in popliteal artery and posterior tibial artery, and thrombosis in right femoral vein. Phlegmasia cerulea dolens was impressed. Enoxaparin subcutaneous injection was initiated. Aggressive thrombolytic therapy was not intended because of concurrent hematuria and gastrointestinal bleeding. The patient died two months later due to aspiration pneumonia.
Risks of developing PCD are malignancy, hypercoagulable state, trauma, pregnancy, and previous femoral vein catheterization. Emergent management to save the limb include systemic anticoagulation, catheter-directed thrombolysis and surgical thrombectomy. PCD-related malignancy has been described in various cancers, mostly in testicular cancer, pancreatic carcinoma, cholangiocarcinoma while prostate cancer was seldom reported. Our case is on androgen deprivation therapy for years, which is considered as an increased risk for venous thrombosis in prostate cancer patients.