Case Study: Swollen Leg with Anemia in an Obese Policeman Leads to Discovery of Cecal Cancer

Summary

We report a case of cecal cancer in an obese policeman, who presented with recurrent deep venous thrombosis and unexplained anemia. The deep venous thrombosis was thought to be due to long hours of standing (professional hazard) and obesity. Investigations for thrombophilia came back negative, but when a thorough investigation was done in search of the cause of his unexplained anemia, an occult cancer of the cecum was diagnosed. A right hemicolectomy was performed with lymph node clearance. The postoperative period was uneventful. We highlight that an unsuspected cecal malignancy may present with deep venous thrombosis. It is uncommon for hollow viscus cancers to present with deep vein thrombosis, but recurrent DVT or thrombosis with unexplained anemia should raise suspicion of an underlying ominous pathology.

Background

Deep venous thrombosis (DVT) is a serious condition, which may have life-threatening consequences, at times. It results from the interplay of a number of predisposing factors and may be the overt manifestation of several underlying pathologies. Recurrent attacks of DVT may occur due to defects in synthesis of coagulation factors or other secondary causes, the most important of which is an underlying malignancy. When the provoking factors are obvious, diagnosis of the primary pathology is easy, and the management is prompt. In absence of a demonstrable predisposing cause (unprovoked DVT), extensive work-up is necessary for diagnosis of the primary pathology. In spite of the extensive investigations, some cases may still elude diagnosis and remain classified as idiopathic. In many of these cases, malignancy may be revealed at a later date, and at an advanced stage. Diagnostic delay may also occur if provoking factors of DVT coexist with an occult malignancy. A strong clinical suspicion is important for its timely management.

Case Presentation

A 45-year-old traffic policeman presented with pain and swelling in his left lower limb associated with a mild fever for the last 7 days. He reported having similar swelling of the contralateral limb one year back, which had subsided with expectant treatment and bed rest. There was no history of dyspepsia, hematemesis/melena, hematochezia, irregular bowel or bladder habits, or loss of appetite or weight. His job involved long hours of standing (7-8 hours per day at a stretch), and he denied any history of hypertension, diabetes, alcohol intake, drug or tobacco consumption, or any history of surgery. There was also no history of such complaints in any member of his family. Examination revealed pallor, mild fever, a BMI of 32.3, and a diffusely swollen left lower limb. The rest of the general examination was unremarkable. The lower limb was diffusely swollen, mild ankle edema was present, and the skin of the lower limb was warm, stretched, shiny, and showed evidence of blanching. There was no evidence of varicose veins, scars of healed ulcers, or petechiae and ecchymoses. Calf tenderness was absent and inguinal lymph nodes were not enlarged. The contralateral limb was apparently normal. Examinations of the abdomen, external genitalia, hernial sites, and rectum were unremarkable. A duplex ultrasound scan was ordered, which showed an acute thrombus in the...

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One Comment

  1. Dr. Valluri Ramarao
    Posted Jul 2014 at 2:41 pm | Permalink

    Yes,nice to search for malignancy.good d/d work up.useful tip.

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