An Unusual Presentation of a Swollen Arm

A Case Report

Monica Kidd; Vina Broderick

Disclosures

J Med Case Reports. 2014;8(26) 

In This Article

Abstract and Introduction

Abstract

Introduction Subclavian vein thrombosis is a rare but potentially fatal condition that most often occurs iatrogenically or in the context of malignancy. Here we report the case of an active, healthy 32-year-old woman who presented with subtle findings of arm pain, paresthesias and skin changes of acute onset and was subsequently diagnosed with upper extremity deep vein thrombosis and subclavian stenosis, and was started on a course of oral antithrombotics.

Case presentation A 32-year-old right-handed Caucasian woman presented to her family medicine clinic with left shoulder pain and numbness along her ipsilateral forearm and hand, as well as subtle swelling of the affected limb. Initially diagnosed with medial epicondylitis, she was later diagnosed with subclavian thrombosis caused by Paget–Schröetter syndrome.
Conclusion Presentations such as these are often attributable to soft-tissue injuries that resolve with rest and sometimes physiotherapy. Subclavian thrombosis was a highly unexpected diagnosis in this case; however, family physicians must remain vigilant in considering rare causes of common clinical presentations which could cause patients significant morbidity if left undiagnosed.

Introduction

Nearly one-quarter of adult Canadians attend a physician for musculoskeletal (MSK) disorders each year,[1] making MSK complaints one of the most common reasons people seek primary care. Most of these cases are benign, so it is understandable for a primary care physician to provide reassurance and symptomatic relief to many patients without exhaustive investigation. However, it is important to remain vigilant for the rare sinister cause of a seemingly benign presentation. Here we report the case of a healthy 32-year-old woman who, after a several-week history of pain and paresthesias, developed a swollen discolored arm. A duplex ultrasound confirmed the presence of a clot in her subclavian vein, a subsequent computed tomography (CT) scan showed subclavian vein stenosis, and venography performed in neutral and in stress positions confirmed bilateral thoracic outlet obstruction. Subclavian vein thrombosis is a rare condition that most often occurs in the context of central venous catheters, surgery or malignancy but, as we describe here, can also have primary causes such as anatomic anomalies and Paget–Schröetter syndrome (so-called "effort thrombosis").[2] As with lower extremity deep vein thrombosis (DVT), upper extremity DVTs (UEDVTs) can be fatal or debilitating if untreated; important complications include pulmonary embolism and post-thrombotic syndrome.[2–6] This case reminds us that it is important for family physicians to maintain a wide differential in presentations of seemingly benign MSK complaints.

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