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    Pallor and swelling in an athlete’s upper arm

    The Case

    A 15-year-old female presents to the emergency department (ED) of a community hospital with acute onset of duskiness in her left arm. She was sitting in class when she noted the sudden color change in her arm accompanied by stiffness and swelling. She did not report any pain in the left arm and there were no symptoms in her right arm. She has never had any similar episodes in the past and has had no recent trauma to her arm or neck. She is not taking any medications and has no known allergies. The patient is on the school softball team and earlier had been practicing at a batting cage.

    Examination

    On presentation to the ED, the patient’s vital signs included a temperature of 98.4°F; heart rate of 67 beats per minute; respiratory rate of 18 breaths per minute; blood pressure of 106/55 mm Hg; and oxygen saturation of 100% on room air. Physical exam of the left upper extremity revealed a full range of motion with mild stiffness, capillary refill of <2 seconds, mild decrease in skin temperature as compared with the right arm, and mild cyanosis. All pulses were 2+ and equal, and radial and ulnar compression tests were both normal. No crepitus or deformity existed of the affected limb. There was full range of motion of elbow and wrists, with intact tendon reflexes. The remainder of the physical exam was within normal limits.

    The girl’s family reported a history of leg clots in her mother and maternal grandmother, but denied a family history of autoimmune disease.

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    Laboratory studies revealed a normal complete blood count, prothrombin time, partial prothrombin time, and comprehensive metabolic panel. The international normalized ratio (INR) was 1.04 (normal, 0.70-1.10) and a D-dimer test was obtained. The D-dimer results were elevated at 292 D-DU ng/mL (0-230 D-DU ng/mL). A duplex ultrasound was ordered (Figure 1) and the patient was transferred to a tertiary care center for further treatment.

    Differential diagnosis

    Pallor and upper extremity edema in a young adult needs to be evaluated in the context of chronicity of symptoms (Table).1-5 A long history of swelling would be more consistent with a lymphatic or arterial abnormality. Congenital or posttraumatic anomalies would not generally present acutely. Additionally, mediastinal masses, causing venous compression, can present as unilateral edema in the absence of thrombosis but it is more likely to cause bilateral arm and facial swelling. The acute onset of swelling is almost always venous in nature and typically is related to venous thrombosis. Ultrasound imaging can confirm the presence of a thrombus in the venous system.

     

    NEXT: Further testing

    Janice F Bistritz, DNP, CPNP, MS
    Dr Bistritz is a pediatric nurse practitioner, Montefiore New Rochelle Hospital, New Rochelle, New York.

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