Case Presentation

A 49-year-old male with a history of ischemic cardiomyopathy, New York Heart Association class II heart failure with an ejection fraction of 35% status post biventricular implantable cardiac defibrillator (ICD), end stage renal disease on dialysis, diabetes mellitus II, and pancreatitis complicated by pseudocyst presented with a sudden onset of left thigh pain with a palpable mass. He denied trauma to the site, numbness, tingling, weakness, fevers, or chills. Review of systems was otherwise negative. Vital signs at presentation were as follows: temperature 98.8°F, pulse 77 beats per minute, blood pressure 150/88 mm Hg, respiratory rate 18 breaths per minute, and oxygen saturation of 96% on 2 liters of nasal cannula. He was notably uncomfortable on exam. The left thigh was edematous on the lateral side and there was tenderness over the distal, lateral portion of the anterolateral left thigh. No tenderness in the calf was noted. He had full range of motion at the hip, ankle, and knee. Straight leg test was negative and pinprick sensation was decreased. Laboratory tests revealed leukocytosis with a white count of 23.1, slight anemia with a hemoglobin of 9.4. Chem 7 revealed BUN of 33 and creatinine of 4.1. Hemoglobin A1c was 8.0 and CPKwas 82. Coags were normal but ESR was elevated at 98. Radiographic studies included x-ray of the left femur, which revealed no fracture or dislocation. Chest x-ray on admission demonstrated a right dialysis catheter, low lung volumes with mild background pulmonary edema and cardiomegaly. Lower extremity ultrasound was negative for deep vein thrombosis. MRI of the left thigh was not obtained due to his ICD. CT scan of the left thigh showed heterogeneously decreased enhancement of the quadriceps particularly within the vastus lateralis; skin thickening with infiltration of the subcutaneous fat, possibly representing cellulitis in the appropriate clinical setting; diffuse atherosclerotic disease with moderate stenoses of the left femoral artery at the level of the adductor hiatus and the left popliteal artery (Figure 1).