Case Presentation: 23 year-old woman presenting with left thigh pain and erythema. Reported rapid onset of pain in left upper thigh and buttock one day prior to admission with no associated fever or chills and no recent trauma to the area. Stated she had had similar symptoms in the same distribution twice over the last two years requiring treatment for cellulitis. She also reported chronic, severe pain in her left leg. Her medical history was significant for scoliosis and left lower extremity deep venous thrombosis associated with pregnancy four years prior.
Left upper thigh and buttock had a large, well demarcated, erythematous patch roughly 20cm x 6cm. Area was warm and acutely tender to light touch. Left lower leg from distal shin to toes was mildly edematous and medial left foot was noted to have non-blanching red discoloration which was non-tender to palpation. Pulses were intact and symmetric in all four extremities. Remainder of exam was normal.
Initial labs included a white blood cell count of 16,900, creatinine 0.67, C-reactive protein 4.80, and sedimentation rate of 12. Lower extremity ultrasound was negative for deep venous thrombosis. She was started on IV Clindamycin due to prior hypersensitivity reactions to penicillins and Vancomycin.
Given the recurrence of cellulitis in the same distribution without inciting injury, the presence of port wine stain over the foot, and mild soft tissue hypertrophy of right lower extremity, a diagnosis of Klippel-Trenauny syndrome was made.
Discussion: Recurrent cellulitis is seen frequently on inpatient and hospitalist services. This case underscores the importance of considering underlying vascular disorders when recurrent cellulitis is encountered, especially in the absence of injury. Klippel-Trenaunay syndrome is a rare disorder featuring capillary or venous malformations, soft tissue or bony hypertrophy, and varicose veins. Effected individuals are prone to cellulitis, superficial vein thrombosis, and pain due to these venous malformations and venous stasis. A patient with recurrent cellulitis, extremity edema, and especially those with port-wine stain, should be evaluated with MRI or ultrasound to determine the extent of venous abnormalities. Surgical intervention with vein stripping or sclerotherapy can be considered when supportive measures, such as compression stockings, are unsuccessful.
Conclusions: Underlying vascular abnormalities should be suspected in the setting of recurrent cellulitis in the absence of trauma or known lymphedema. Klippel-Trenaunay syndrome is a rare example of such vascular malformations and can be exceptionally debilitating to those affected.
To cite this abstract:Voigt, L. A RECURRENT PAIN IN THE REAR. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 907. https://www.shmabstracts.com/abstract/a-recurrent-pain-in-the-rear/. Accessed September 22, 2019.