Famous Patients, Famous Operations, 2003 - Part 6: The Case of the Elderly Writer With a Swollen Leg

Albert B. Lowenfels, MD

Disclosures

December 30, 2003

Introduction

An 80-year-old male writer presented with a chief complaint of a dragging, persistent pain in his left leg, severe enough to interfere with walking, and which he attributed to previously diagnosed "rheumatism." A physician in a local arthritis clinic noted that the left leg was markedly swollen and made a diagnosis of venous thrombosis. Soon afterward, the patient was seen by an internist, who concurred with the diagnosis of venous thrombosis and ordered anticoagulant therapy. Five days after the initial onset of symptoms and 2 days after beginning anticoagulant therapy, the patient was flown to a regional hospital where he received cold compresses to the leg, penicillin, and continued anticoagulant therapy.

Past History: Patient had numerous vague abdominal complaints, which included occasional bouts of indigestion or "gastritis." He also complained of episodes of exhaustion and headache over a period of many years. Nine years before the present illness, he had undergone right lower and middle lobe lobectomy for carcinoma of the lung. His postoperative recovery was uneventful. Eight years prior to admission he fell, sustaining a fracture of the humerus. Later that same year, he had a serious nosebleed requiring electrocautery.

Family and Social History: The patient's father died of bladder cancer when he was in his 50s, and his brother died of lung cancer. The patient was a lifelong heavy smoker, even after resection of his lung tumor. He was rejected for military service for health reasons. He was a social drinker. He traveled extensively in Europe and the United States.

Physical Examination (upon admission to regional hospital): The patient is a tall, elderly male complaining of some tenderness in the left leg, which was swollen and edematous but otherwise comfortable. There was no information available about the presence or absence of peripheral pulses. Blood pressure was elevated, and skin was somewhat pale and without icterus. There was a well-healed right thoracotomy scar; no abdominal scars or masses were seen.

Disease Course: The patient was treated with bed rest and anticoagulants, but was allowed to get up and sit in a chair. On the 24th day after onset of symptoms, the patient took a short walk in the hospital corridor, which precipitated sudden weakness, hypotension, and syncope. That night, his condition deteriorated with complete circulatory collapse and a short period of unconsciousness. He received several blood transfusions, intravenous fluids, corticosteroids, oxygen, and injections of morphine. He remained conscious until shortly before his death on the 25th day after initially complaining of a swollen leg.

Who was our mystery patient?

  1. George Bernard Shaw

  2. Charles Dickens

  3. Thomas Mann

  4. William Shakespeare

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Which of the following diseases is unlikely to be related to the final illness?

  1. Pulmonary embolus

  2. A sudden hemorrhage from a ruptured blood vessel

  3. Thrombosis of the iliac vein

  4. Recurrent lung cancer

  5. Acute hemorrhagic pancreatitis

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What was the cause of death?

  1. Pulmonary embolus

  2. Sudden hemorrhage from a ruptured blood vessel

  3. Thrombosis of the iliac vein

  4. Recurrent lung cancer

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What was the cause of the venous thrombosis and leg edema?

  1. Stasis of blood from prolonged bed rest

  2. Compression of the iliac vein from a retroperitoneal hematoma

  3. Clotting abnormality

  4. Longstanding thrombophlebitis

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What were the autopsy findings?

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Have there been any other reports of venous occlusion secondary to arterial disease in the iliac vessels?

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Is there an association between thrombophlebitis and cancer?

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How would this patient be managed today?

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What are the details of Mann's lung operation?

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What other Nobel Prize winner died the same year with a similar disease?

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