Phlegmasia Cerulea Dolens Post Lung Transplant: A Case Report

ABSTRACT

Phlegmasia cerulea dolens (PCD) is a rare, life-threatening manifestation of deep vein thrombosis (DVT). PCD is characterized by limb swelling, ischemia, pain and cyanosis. It can lead to gangrene requiring amputations with high mortality rates. Here, we report a case of a patient with PCD in the setting of lung transplantation. A 55-year-old female ex-smoker with ILD secondary to rheumatoid arthritis complicated by post-COVID fibrosis 6 months prior was referred for lung transplant. She had recovered from a cerebral vein thrombosis around the time of her COVID. An acute pulmonary embolism during evaluation prompted therapeutic anticoagulation. She was accepted for lung transplant but deactivated for four weeks due to COVID re-infection. During this time, she developed a pelvic hematoma. She was reactivated and underwent bilateral lung transplant. Her initial post-operative course was complicated by prolonged ventilator weaning. On post op day 23, she developed a nonocclusive thrombus in the left common femoral vein. Due to her history of spontaneous bleeding on anticoagulation, an IVC filter was placed. The next day, the patient noted pain in bilateral lower extremities and inability to move her left leg. On exam, her bilateral lower extremities were cool to touch with decreased sensation and pulses as well as skin mottling extending to the lower abdomen. CTA showed no evidence of vascular compromise. The next day, labs showed increasing creatine kinase and worsening anemia. Repeat ultrasound showed occlusive thrombus in bilateral lower extremities with reduced ABI's and no detectable TBI's. Vascular surgery was consulted. She was placed on anticoagulation with heparin. Imaging 24 hours later showed no flow beyond the left proximal calf concerning for phlegmasia. She underwent IVC filter removal, percutaneous ilio-caval and bilateral femoral suction thrombectomy, and bilateral lower extremity four compartment fasciotomies. Repeat ultrasound showed extensive ileofemoral and IVC DVT with ongoing phlegmasia. The care team considered left above the knee amputation, but the patient was transitioned to comfort care given worsening multiorgan failure including poor neurological status. To the best of our knowledge, ours is the first reported case of PCD in a patient post-lung transplant. In this case, it was prudent to place an IVC filter but perhaps it contributed to the PCD. [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)