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Clinical Summary

Phlegmasia alba dolens (painful white leg, or milk leg) is caused by massive thrombosis of the iliofemoral veins and is characterized by pitting edema of the entire lower extremity, inguinal area tenderness, and a pale extremity secondary to arterial occlusion. Phlegmasia cerulea dolens (painful blue leg) arises from massive thrombosis of the lower extremity veins, including the perforators and collaterals, resulting in venous ischemia with a cool, painful, swollen, tense, and cyanotic-appearing lower extremity. Occasionally, there is bullae formation; compartment syndrome and gangrene may follow. The differential includes arterial insufficiency or thrombosis, aortic dissection, abdominal aortic aneurysm, cellulitis, and lymphedema. Doppler ultrasound and CT venography (most accurate for determining extent) are used for diagnosis.

FIGURE 12.43

Phlegmasia Alba Dolens. Pale discoloration of the lower extremity. (Reproduced with permission from Wolff K, Johnson R, Saavedra AP, Roh EK. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. 8th ed. New York, NY: McGraw Hill; 2017.)

FIGURE 12.44

Phlegmasia Cerulae Dolens. Bluish discoloration and swelling of the left lower extremity. (Photo contributor: Daniel L. Savitt, MD.)

Management and Disposition

Systemic anticoagulation with heparin should be initiated immediately; vascular surgery or interventional radiology should be consulted. There is a significant rate of pulmonary embolization and a high incidence of postphlebitic syndrome due to venous valvular incompetence. Endovascular techniques for pharmacomechanical clot dissolution are showing promising results for treating these patients.

Pearls

  1. Pregnancy is one risk factor for phlegmasia alba dolens.

  2. About 40% of patients with phlegmasia cerulea dolens have an underlying malignancy.

  3. Hypotension may result from venous pooling of blood in the lower extremity and diminished venous return.

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