Mystery Quiz

Vivian Hayashi MD, Robert Smith MD

The patient is a 78 year old man who presented to the emergency room with fever, pain, swelling, and erythema of the right leg over a two day period. The patient denied abdominal symptoms, cough or breathlessness over his baseline. His past medical history included Waldenstrom’s macroglobulinemia ten years earlier that responded to treatment with chlorambucil. Other morbidities included severe chronic obstructive pulmonary disease, myocardial infarction 20 years previously, and chronic venous insufficiency resulting in lower extremity edema. The patient was a non-smoker who had previously worked at a bank. Physical exam was significant for a fever of 102F but vital signs were otherwise normal. Heart and lung exam were unremarkable; extremities showed bilateral pitting edema, right greater than left with erythema of the right lower leg and tenderness over the calf. Labs showed WBC 3.8k, Hgb 7.4gm, and platelets 47k (consistent with baseline pancytopenia). The admitting chest radiograph is shown below:

 

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