Abstract
An 81-year-old female presented with acute on chronic right leg swelling and discoloration. Pertinent medical history included chronic lymphocytic leukemia (CLL) on treatment with acalabrutinib and bilateral chronic venous insufficiency. Prior to presentation, she minimally traumatized her distal right leg with resultant increased swelling. Subsequent treatment included a below knee graduated compression stocking that the patient purchased over the counter. Shortly after compression application, she developed a purplish discoloration throughout the calf that was most pronounced along the upper stocking margin. Although an above knee graduated compression stocking was substituted, the discoloration persisted and ascended to the distal thigh under the proximal stocking edge. Right lower extremity examination was significant for a composite of nearly confluent multicolored ecchymosis, purpura, petechiae, and underlying stasis pigmentation. The discoloration extended from the dorsal foot and terminated at the distal thigh with irregular circumferential demarcation (Panels A and B). Scattered reticular and spider veins were present bilaterally and peripheral pulses were 2+/2. A complete blood count documented: white blood cell 33 K/μL, hemoglobin 12.0 g/dL, and platelet 93 K/μL.
The patient was ultimately diagnosed with Rumpel–Leede phenomenon (RLP), a benign sign of pressure mediated acute dermal capillary rupture manifested by self-limited well-demarcated petechiae, purpura, and/or an erythrocyanotic rash. RLP has been reported after venous occlusion from phlebotomy tourniquets or sphygmomanometry typically in patients with capillary fragility and a bleeding diathesis such as thrombocytopenia.1,2 Our patient’s RLP was triggered by the proximal margin of the compression stocking in the setting of a multifactorial susceptibility including CLL-mediated qualitative and quantitative platelet defects, acalabrutinib, and venous hypertension. We concluded that the patient’s compression stocking was too tight in the setting of underlying coagulopathy. Of interest, acalabrutinib has been shown to cause bruising, ecchymosis, and petechiae in up to 21% of patients. 3 Recognition of the RLP is crucial in order to avoid costly and unnecessary diagnostic testing and therapy. Most cases resolve within several weeks although some may require several months to abate. We recommended discontinuation of our patient’s compression stocking and a follow up visit.
‘Images in vascular medicine’ is a regular feature of Vascular Medicine. Readers may submit original, unpublished images related to clinical vascular medicine. Submissions may be sent to: Heather Gornik, Editor in Chief, Vascular Medicine, via the web-based submission system at http://mc.manuscriptcentral.com/vascular-medicine
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
