A 54-year-old man comes to the office due to 2 days of redness and pain in his right arm. He was recently diagnosed with superficial thrombophlebitis involving the left lower and upper extremities. His symptoms then subsided within days of nonsteroidal anti-inflammatory drug therapy only. The patient has no other past medical history. He has some abdominal discomfort that he attributes to gastroesophageal reflux disease. Temperature is 37.6 C (99.7 F). On examination, there is erythema and tenderness extending linearly from the right forearm to just anterior to the right antecubital fossa. No fluid collection is palpable. Complete blood count shows mild leukocytosis. The patient's symptoms may indicate the presence of which of the following?

Question

A 54-year-old man comes to the office due to 2 days of redness and pain in his right arm.  He was recently diagnosed with superficial thrombophlebitis involving the left lower and upper extremities.  His symptoms then subsided within days of nonsteroidal anti-inflammatory drug therapy only.  The patient has no other past medical history.  He has some abdominal discomfort that he attributes to gastroesophageal reflux disease.  Temperature is 37.6 C (99.7 F).  On examination, there is erythema and tenderness extending linearly from the right forearm to just anterior to the right antecubital fossa.  No fluid collection is palpable.  Complete blood count shows mild leukocytosis.  The patient's symptoms may indicate the presence of which of the following?

Quizplus · Accepted Answer

Migratory thrombophlebitis should raise suspicion for cancer. Hypercoagulability is a very common paraneoplastic syndrome seen most frequently in visceral adenocarcinomas of the pancreas, colon, and lung. Hypercoagulability develops because adenocarcinomas produce a thromboplastin-like substance capable of causing chronic intravascular coagulations that can disseminate and tend to migrate. Migratory superficial thrombophlebitis, known as Trousseau syndrome, is named after Armand Trousseau, a well-respected French physician who first described the association with cancer. Trousseau later diagnosed his own visceral cancer after developing the syndrome. Trousseau also described the Trousseau sign (hand/forearm muscle spasms on sphygmomanometric measurement) associated with hypocalcemia. (Choice A) Celiac sprue has been associated with a hemorrhagic diathesis (rather than abnormal thrombosis). The malabsorption resulting from celiac sprue can result in vitamin K deficiency. (Choices B and D) Polycystic kidney disease is not among the conditions commonly associated with an acquired prothrombotic state. Disseminated chlamydia infections are classically associated with reactive arthritis (not thrombophlebitis), and infections in general can create a systemic inflammatory state that favors thrombosis. However, malignancy would be a more likely explanation for migratory superficial thrombophlebitis accompanied by vague abdominal pain. (Choice C) Hyperthyroidism has been associated with a hypercoagulable state and is occasionally reported in cases of cerebral venous thrombosis, but there is no evidence of a significant association with venous thrombotic events. Educational objective: A paraneoplastic syndrome of hypercoagulability may be seen in some patients with cancer, especially adenocarcinomas of the pancreas, colon, or lung. Superficial venous thromboses may therefore appear in one site and then resolve, only to recur in another site. This is known as Trousseau syndrome (migratory superficial thrombophlebitis), an indication of visceral cancer.

A 54-Year-Old Man Comes to the Office Due to 2