A Sinister Development

A CLINICAL PROBLEM-SOLVING article by Reza Fazel from Emory University in Atlanta, Georgia.
A 35-year-old woman presented to the emergency department with a 2-day history of progressive swelling and pain in her left leg, without antecedent trauma. She also reported mild dyspnea during the previous day, with no associated chest discomfort.
Six months earlier, she had given birth to a healthy infant by vaginal delivery at term; her pregnancy had been uncomplicated. Her only medications were oral contraceptives and a multivitamin.
In the emergency department, she was not in acute distress and was afebrile. Her left leg showed no evidence of trauma but there was considerable swelling extending from her ankle to the upper thigh, and the area of the swelling was markedly tender to palpation. The leg was slightly pale with diminished but palpable pulses.
Doppler ultrasonography of the veins in her left leg showed abnormally sluggish blood flow in the proximal deep venous system but was inconclusive for thrombus. A ventilation–perfusion scan of the lung was normal.
Intravenous unfractionated heparin was started, and the patient was hospitalized for further evaluation of the cause of pain and swelling in her left leg.

May-Thurner症候群、aka腸骨静脈圧迫症候群：左総腸骨静脈は右総腸骨動脈と交差して いますが、この交差する部分で腸骨静脈が腸骨動脈と背側にある椎体との間で圧排されることで血流障害が生じ、何らかの誘因で左下肢のDVTを引き起こすものです。左ということが肝で、タイトルの"sinister"には、「不遇な」と同時に「左の」という意味があります。