Flegmasia cerulea dolens: reporte de un caso y revisión de la literatura / Flegmasia cerulea dolens: case report and literature review

Phlegmasia Caerulea Dolens is a rare complication of deep vein thrombosis. It presents with a sudden onset of pain, swelling, discoloration and arterial compromise of the affected limb. There’s usually history of prothrombotic events such as malignancy, femoral vein catheterism, antiphospholipid syndrome, recent surgery, pregnancy, etc. Left without treatment, it can evolvein to gangrene, septic shock and death. Diagnosis usually only requires clinical appreciation.Confirmation can be done with ultrasonographic studies with doppler. Treatment can be both medical and surgically based. Medical therapy can be done with heparin and elevation of the affected limb or the use of thrombolytic, whilst surgical therapy can be either venous thrombectomy or amputation. We present the case of a 57-year old smoker, diabetic, and with systemic lupus erythematosus history female patient, that goes to the emergency room with sudden left leg pain, with cyanosis and absence of distal pulses. Besides she presented with lower respiratory symptoms. Diagnosis was confirmed with ultrasound and CT pulmonary angiography was performed showing pulmonary embolism. Medical treatment was initiated with good response.

Fascitis necrosante grave por Serratia marcescens: Reporte de un caso clínico / Fatal necrotizing fasciitis due to Serratia marcescens

Una paciente de 81 años con insuficiencia cardíaca crónica, fibrilación auricular y tratamiento anticoagulante, ingresó por un cuadro fulminante de dolor y celulitis en la extremidad inferior derecha de 24 horas de evolución. Sobre la zona existía una úlcera crónica de cinco meses de evolución, manejada con curaciones locales. Al ingreso, había una placa necrótica pero sin hipotensión o confusión mental. La paciente estaba febril y con taquicardia (126 por min). La evaluación reveló ausencia de leucocitosis, trombosis venosa profunda en la misma pierna e infiltrados radiológicos pulmonares en el lóbulo inferior izquierdo. En las horas siguientes aumentó el dolor, apareció secreción purulenta por la úlcera y la paciente presentó confusión, hipotensión, falla respiratoria y luego shock. La paciente recibió ciprofloxacino endovenoso y clindamicina y fue intervenida a las 15 horas de ingreso, efectuándose una amputación supracondílea. El sondeo cardíaco demostró un gasto bajo (2,3 L/min) y una resistencia vascular sistémica (2888 din.s.cm"5) y presión capilar pulmonar elevada (17 cm H(2)0), cifras compatibles con un shock cardiogénico. Evolucionó en malas condiciones y falleció de falla orgánica múltiple a las 36 horas de ingreso. Los hemocultivos demostraron crecimiento de Serratia marcescens en dos frascos. No se efectuó una necropsia y los cultivos de la secreción de la úlcera fueron negativos.

An 81 year old female patient with chronic heart failure and atrial fibrillation receiving anticoagulant therapy, was admitted with progressive pain on her right leg for the past 24 hours, associated to local erythema, edema and warmth. The lesion evolved at the same site where she presented a chronic ulcer for the previous 5 months managed only with local care. At admission a necrotic plaque on the affected site was perceived; there was no hypotension or mental confusion but signs of a deep venous thrombosis on the involved leg were found. She was febrile (37.8°C) and with tachychardia (126 per minute). Laboratory evaluation revealed normal white blood cell count and a subtherapheutic anticoagulant INR value. A chest x-ray showed infiltrates on the left lower lung lobe. On the following hours the lesion evolved with increasing pain, haemorrhagic bullae and a purulent discharge through the ulcer, with the patient developing mental deterioration, hypotension, respiratory failure and shock. The patient received intravenous ciprofloxacin and clindamycin and was operated 15 hours after admission performing an over-the knee amputation. A cardiac catheterization demonstrated a low cardiac output (2.3 L/min), and both a high systemic vascular resistance (2888 din.s.cm"5) and pulmonary capillary wedge pressure (17 cm H(2)0), results compatible with cardiogenic shock. Evolution was progressively worse and she died of multiple organic failure 36 hours after admission. Two blood culture samples grew Serratia marcescens. No necropsy was performed and cultures taken from the leg remained negative.