A n 83-year-old man with a recent history of thyroid carcinoma presented with sudden pain and swelling of the left leg with bluish discoloration and livedo reticularis throughout. Two days before admission, swelling of the left lower extremity developed, and the diagnosis of partial left femoral vein thrombosis was confirmed by venous duplex ultrasonography and compression ultrasound. Anticoagulation with low-molecular-weight heparin and oral warfarin was initiated, and the patient was discharged home receiving maintenance anticoagulant therapy and wearing compression stockings.On arrival, the patient's arterial blood gas analysis and 12-lead ECG were normal. His blood pressure was 127/ 78 mm Hg, pulse rate was 84 bpm, and respiratory rate was 16 breaths per minute. His international normalized ratio was 1.2 (normal range, 0.8 -1.2) and D-dimer level was 2530 g/L (normal range, Ͻ190 g/L). On physical examination, the left leg was markedly swollen, violaceous, painful, tender, and slightly warm up to the inguinal regions (Figure 1). Compression ultrasound was performed again, and an occlusive thrombus was visualized from the left common iliac vein to the calf veins (Figure 2). A diagnosis of phlegmasia cerulea dolens was made, and to prevent potential irreversible venous gangrene and subsequent limb loss, the patient underwent catheter-directed thrombolysis combined with thrombectomy and showed subsequent symptomatic improvement. Seven days later, during oral anticoagulation therapy, the limb discoloration was entirely resolved (Figure 3), and recanalization of the limb vessels was apparent on power Doppler (Figure 4).Phlegmasia cerulea dolens is a rare syndrome caused by diffuse venous thrombosis that is characterized by sudden

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Figure 1 (A) Ultrasound scan of abdomen showing a single, large stone within the gallbladder. (B) Plain abdominal x ray, after a barium meal, showed multiple air-fluid levels and a calcified mass in the upper right abdomen (arrow) suggestive of an ectopic gallstone. (C) The stone extracted surgically.