An Unusual Presentation of a Swollen Arm

A Case Report

Monica Kidd; Vina Broderick


J Med Case Reports. 2014;8(26) 

In This Article

Case Presentation

A 32-year-old right (R)-handed Caucasian woman presented to her family medicine clinic with a several-week history of left (L) shoulder pain and numbness along her ipsilateral forearm and fifth finger, exacerbated by elbow extension against resistance. She was initially diagnosed with medial epicondylitis and treated with a non-steroidal anti-inflammatory drug; no differential diagnosis was noted by the original physician but it would have included conditions that can lead to brachial plexopathy, including trauma, compressive tumor, cervical radiculopathy, and spinal stenosis.

When she awoke the following morning, her L arm had become swollen and discolored, so she returned to the clinic. On examination, her L arm was subtly swollen (L upper arm circumference 33cm and 31.5cm on R; L lower arm circumference 23cm and 21cm on R) with a similarly subtle purplish discoloration over the dorsal aspect of her distal L forearm (Figure 1). Both limbs were warm, and radial pulses and capillary refill in her fingers were normal bilaterally. The range of motion in her shoulders, elbows and wrists was normal bilaterally, and deep tendon reflexes at her elbows and wrists were intact. She displayed numbness over her dorsal and ventral L forearm, as well as the lateral aspect and palm of her L hand, but was neurologically intact on the R. She was afebrile and normotensive. Her chest was clear and her heart sounds were normal. She had been previously well, was a non-smoker and had nothing in her history to suggest a Pancoast tumor. She was involved in regular cross-training exercises and had intentionally lost approximately 40kg over the previous 3 years, giving her a body mass index of 25.8. She worked in an office and was engaged to be married in the near future. Her only medication was an oral contraceptive pill (OCP) containing drospirenone.

Figure 1.

Subtle arm swelling and discoloration associated with subclavian thrombosis.

X-rays of her chest, shoulder and elbow were normal; duplex ultrasound showed subclavian vein thrombosis, even though this can be a challenging diagnosis to make because ultrasound visualization of the area is difficult and the subclavian vein cannot be compressed.[7] She knew of no personal or family history of venous thromboembolic disease. Her OCP was discontinued because we were concerned the clot could be hormone-related, and we referred her to hematology. Although current guidelines do not include evaluation for thrombophilia in the decision of whether or how to treat venous thrombosis,[7] hereditary risk factors for thrombosis do affect length of treatment and sometimes monitoring,[8] so the standard hypercoagulable screen available in our center was ordered. The screen showed she was negative for lupus anticoagulant, and that her levels of antithrombin, protein C and protein S were all normal; neither did she carry Factor V Leiden or prothrombin allele mutations. She was immediately started on a 3-month course of anticoagulation, beginning with low-molecular-weight heparin injections and a vitamin K antagonist, according to current guidelines (Grade 1B evidence);[9] she was also prescribed a compression sleeve, although there is Grade 2C evidence against this. Her heparin was discontinued when her international normalized ratio (INR) became therapeutic.

A subsequent CT scan with intravenous contrast injected on the R (contralateral side) showed stenosis of her R subclavian vein from the thoracic inlet to its origin with her superior vena cava. There was no lung pathology. Unfortunately, characterization of the affected side was not possible with this study and was not repeated. She was referred to vascular surgery. A venogram was ordered there and it demonstrated bilateral obstruction of her subclavian veins, with significant stenosis on the L (ipsilateral) side, and complete obstruction on the R (contralateral) side with stress maneuvers, consistent with bilateral thoracic outlet syndrome and resolved Paget–Schröetter syndrome on the L. She was offered bilateral rib resection and at the time of writing is considering her options.