Journal of Clinical and Aesthetic Dermatology

DEC 2017

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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50 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY December 2017 • Volume 10 • Number 12 B R I E F R E P O R T leukopenia (2.1k/μl), thrombocytopenia (3.6k/μl), and nucleated red blood cells. A peripheral blood smear (PBS) showed blasts, presence of Auer rods, and tear drop cells, indicative of acute myelogenous leukemia (AML). Case 2. A woman in her 80s with hypertension, peripheral neuropathy, and a previous pulmonary embolus was sent to the ED with lower extremity erythema, leukocytosis, and a failure to improve after cephalexin treatment. A physical exam showed linear, serpiginous erythema over the right arm, left medial thigh, and diffusely over the left medial tibia (Figure 2). Her VDS was "negative." Flow-cytometry and a bone marrow biopsy demonstrated hypogranular AML. She was diagnosed with AML via bone marrow biopsy and treatment with decitabine was initiated. Subsequent clinical resolution of her thrombosis followed. Case 3. A woman in her 70s with a history of anemia, asthma, and glaucoma was referred to the ED for right leg erythema that failed to improve with antibiotics. She was found to have leukocytosis to 325.8k/ μl. A physical exam showed an erythematous cord, with significant pain along left medial malleolus. The right lower extremity exhibited a serpiginous streak along the lateral and posterior portion from the knee to the ankle (Figure 3). Streaks of pigmentation extended laterally from this longitudinal axis. Her lower extremity VDS was "negative." After leukophoresis and during early initiation of tretinoin treatment, she suffered a cerebrovascular accident and her family opted for comfort care. DISCUSSION Serpiginous cord morphology and cord-like palpability are distinguishing features of SMT. 4 Additionally, SMT preferentially afflicts the small and great saphenous veins of the lower extremities but can have a diffuse migrational distribution as well. 5 The linear or serpiginous pattern of the purpura and palpable cord- like nodules, and the combination of both, almost certainly indicates superficial thrombophlebitis. The distinct linear serpiginous cords and palpability are caused by a hypercoagulable state (conferred by tissue), cancer procoagulants activating coagulation factor VII, and leukocytotic sludging. 5 Cancers that are commonly seen in- clinic in association with SMT are pancreatic cancer, other gastrointestinal cancers, and various leukemias. 5 Up to 30 percent of cases are detected only after a follow-up VDS. 6 Therefore, knowledge of the diagnostic test and its limitations is critical. In the three cases presented here, the patients were admitted with a primary diagnosis of cellulitis, not because SMT was not considered, but rather because the diagnostic test did not support it. VDS results are technician-dependent. SMT might be missed due to the following errors: failure to maximize venous pressure via patient positioning, lack of appropriate transducer frequency (7–12MHz), venous constriction secondary to cold room temperatures, and/or incorrect transducer positioning. 7 Additionally, miscommunication could also contribute to diagnostic errors. Ultrasound technicians are often unaware that a patient has suspected SMT and, due to this miscommunication, the technicians fail to perform VDS within the affected inflammed area. Furthermore, technicians might be hesitant to apply transducer pressure over the SMT due to patient pain. Technicians also do not generally evaluate the small saphenous vein without a specific request. CONCLUSION These three cases illustrate that pseudocellulitis might have severe associations and is often misdiagnosed, resulting in a delay of treatment of the severe FIGURE 1. Case 1 presentation—A man in his 50s who presented with fever and left calf eruption FIGURE 2. Case 2 presentation—A woman in her 80s who presented with lower extremity erythema, leukocytosis, and a failure to improve after cephalexin treatment FIGURE 3. Case 3 presentation—A woman in her 70s who presented with right leg erythema that failed to improve with antibiotics

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