A 55-year-old woman comes to the office due to pain, itching, and red streaks on her left arm. She had a similar episode on her chest almost 2 weeks ago that improved on its own. Review of systems is positive for heartburn and mild upper abdominal pain for the last several months that is partially relieved by antacids. The patient has a 15- to 30-pack-year smoking history and drinks alcohol occasionally. Physical examination shows mild epigastric tenderness to palpation. The lungs are clear to auscultation. There are no murmurs on cardiac examination. She has tender, erythematous, and palpable cord-like veins on the left arm and upper chest. Which of the following is the best next step in management of this patient?

Question

A 55-year-old woman comes to the office due to pain, itching, and red streaks on her left arm.  She had a similar episode on her chest almost 2 weeks ago that improved on its own.  Review of systems is positive for heartburn and mild upper abdominal pain for the last several months that is partially relieved by antacids.  The patient has a 15- to 30-pack-year smoking history and drinks alcohol occasionally.  Physical examination shows mild epigastric tenderness to palpation.  The lungs are clear to auscultation.  There are no murmurs on cardiac examination.  She has tender, erythematous, and palpable cord-like veins on the left arm and upper chest.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient's presentation suggests migratory superficial thrombophlebitis, classically known as Trousseau syndrome. Trousseau syndrome is a hypercoagulable disorder that usually presents with unexplained superficial venous thrombosis at unusual sites (eg, arm, chest area). The syndrome is usually diagnosed prior to (sometimes months to years before) or at the same time as an occult visceral malignancy. Trousseau syndrome is usually associated with cancer involving the pancreas (most common), lung, prostate, stomach, and colon, and acute leukemias. Factors associated with higher risk of pancreatic cancer include increasing age and smoking. The tumor likely releases mucins that react with platelets to form platelet-rich microthrombi. This patient with a history of heavy smoking, abdominal pain, and migratory thrombophlebitis should be referred for CT scan of the abdomen to evaluate for an occult tumor (eg, pancreatic carcinoma). (Choice A) Peripheral septic thrombophlebitis is most often associated with breaks in the skin due to catheters, venipuncture, or intravenous injections. Patients often present with fever and pain with swelling at the infection site. However, this patient's absence of fever or history of catheterization or injection makes this less likely. (Choice B) Barium swallow is useful for evaluating esophageal abnormalities (eg, dysphagia, odynophagia) or documenting aspiration. However, it is not as useful for evaluating suspected pancreatic or gastric cancer. (Choice C) Trousseau syndrome is much more commonly associated with pancreatic rather than colon cancer. Colonoscopy is indicated for patients with anemia and positive fecal occult blood tests. It may be required in this patient if initial abdominal CT does not reveal a pancreatic tumor. (Choice E) D-dimer testing is useful in low-risk patients with suspected deep venous thrombosis and/or pulmonary embolism. However, results may be elevated and less useful in patients with signs of migratory superficial thrombophlebitis and suspected malignancy. (Choice F) This patient's chest pain is most likely due to superficial thrombophlebitis. She has no signs or symptoms of heart failure or valvular disease (eg, shortness of breath, peripheral edema, murmurs on physical examination) and does not require an echocardiogram. Educational objective: Trousseau syndrome is a hypercoagulability disorder presenting with recurrent and migratory superficial thrombophlebitis at unusual sites (eg, arm, chest area). It is usually associated with an occult visceral malignancy such as pancreatic (most common), stomach, lung, or prostate carcinoma. References: Trousseau's syndrome: multiple definitions and multiple mechanisms. (http://www.ncbi.nlm.nih.gov/pubmed/17496204) Trousseau's syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/8317122)

A 55-Year-Old Woman Comes to the Office Due to Pain, Itching