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Painful calfJulie Samuel
Consultant Microbiologist, Newcastle upon Tyne
68 male
Multiple Myeloma diagnosed on routine blood tests
Past medical history: prostate cancer in remission, treated with radiotherapy and hormone therapy
2010
8 cycles of chemo pre transplant
Chemotherapy regime
CTDA‐cyclophosphamide, thalidomide and dexamethasone.Also tinzaparin prophylaxis due to high risk of DVT
Autologous stem cell transplant 09/02/2012‐melphalan, at home with daily review, doing squats at home and mobile
18/02/12‐ 02.20 am Pain in left calf, difficulty in walking, tender to touch,
peripheral neuropathy secondary to thalidomide Other observations stable 5 hrs later‐worse, warm foot, tenderness ++, normal
sensation, palpable post tibial pulse 12.40 pm: left calf swollen, painful and slightly purple,
pulses good, sensations normal, toes warm slightly cooler than right
Deep Vein Thrombosis Muscular Cramps Intermuscular bleed secondary to low platelets Cellulitis Compartment syndrome
Differential diagnoses
Neut 0, platelets 5, CRP 92, capillary refill 3 secs, D dimer 2942, PT 16 seconds (normal range 10‐13), APTT 22 seconds (normal range 25 ‐37)
Blood culture USG left leg
Normal compressibility, flow and augmentation of flow in the common femoral, superficial femoral and popliteal veins on the left, calf veins present. No evidence of collection. Left calf muscles diffusely swollen. No left sided DVT
Investigations
Platelet transfusion IV antibiotics‐ Piperacillin/tazobactam Vascular referral IV vitamin K Analgesia‐ IV morphine
Management
Redness and tracking left calf/thigh, hypotensive, IVT resuscitation
BP 85/56, apyrexial.Plt 6, neut 0.2, wcc 0.4, Hb10On examination:erythema ++ posterior knee and thigh, no skin breaks or insect bites, no crepitus, power and sensation normal throughout
16 hours later
DD: spontaneous haemorrhage secondary to low platelets exacerbated
by exercise cellulitis leading to neutropenic sepsis
Further Management:
1.50 lts fluid – no BP response, anuric, plts 20 post 2 units transfusion, ABG ph 7.4, pco2: 3.7, po2: 12.5, neut: 0.00, Na: 132, K: 4.2, urea: 13.8,
creatinine: 189, CRP: 163
Repeat colloid bolus, Review antibiotics, CK, catheterise
18/02/12
19.20 pmCK > 30,000‐ rhabdomyolysis
Blood Culture‐ Streptococcus dysgalactiae Group C/G (collected 7.48 am)(Identified by MALDI‐ToF)
19.45 pm: orthopaedics reviewRequested CT scan to exclude gasImpression cellulitis, clindamicin added to Piperacillin/tazobactam
20.45 pm: plastic surgeon‐ impression ? Myositis
21.30 pm: CT lower limb: no gas, diffuse swelling of muscles in all three compartments with extensive subcutaneous edema.
22.00 pm: Transferred to ITU for haemodynamic support ( low BP despite 4 lts)
Impression: Compartment syndrome for urgent fasciotomy
Immediate post op
Day 7 post op
Post op: respiratory, renal and circulatory support. On GCSF and antibiotics
Clindamicin stopped on day 10 and piperacillin/tazobactam on day 7
Discharged from ITU after 12 days‐ CVVH changed to haemodialysis
Discharged home after 1.5 months with weekly outpatient review
Mobilised with zimmer , no pain, normal sensation in foot, renal functions improving
Regular tissue viability input – aquacel dressing, VAC pump
Wound exudate +++ Pseudomonas aeruginosaisolated from swabs‐ no antibiotics commenced
For skin graft when platelets recovered Type 2 MI secondary to sepsis and vasopressors
Week 3
Wound : green discharge, given flucloxacillin + metronidazole‐ nauseated vomited and high temps changed to IV Pip/taz,
low BP 77/52, hot and sweaty, platelets 32, neutrophils 0.45, CRP 201
Teicoplanin added BP improved with fluid resuscitation Leg wound‐4cm wide small area of healthy granulation tissue otherwise very sloughy
2 months later..
Blood culture‐ Pseudomonas aeruginosa‐ continued on antibiotics
Antibiotic changed to meropenem and stat gent 5mg/kg due to ongoing pyrexia treated for 7 days
Plastics review‐wound bed granulating but dusky with fibrinous areas. No evidence of clinical infection.
Continued..
Legs healing‐ anterior and posterior wounds almost healed, calf swelling significantly reduced. Able to walk unaided except when on long walks.
Neut 3.8 Platelets 76 IgG 19.6 No plans for Split Skin Graft, continue with conservative management with review in 8 weeks
May 2012
June 2012
Trip to NICE Wound healing, platelets recovering Paraprotein static Review in 6 weeks
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