A 73-year-old man with a history of bronchial adenocarcinoma with metastases to the brain, liver and vertebrae presented to our emergency medicine department. He had a history of an acutely painful swollen left leg with bluish discolouration of the foot (fig 1). He had been admitted 1 month earlier with multiple pulmonary emboli and had been given warfarin; no deep vein thrombosis was found at that time. Peripheral pulses were not palpable and capillary refill time was prolonged. Doppler ultrasound revealed thrombus extending from the popliteal vein proximally to the left external iliac vein.

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Figure 1 Swollen left leg with bluish discolouration of the foot.

Phlegmasia cerulea dolens, first recognised 400 years ago by Fabricius Hildanus, is a rare and often devastating complication of deep vein thrombosis with a reported mortality of 25; amputation is required in 25 of those who survive.1 It results from thrombosis involving both major deep venous channels of the extremity and collateral veins, resulting in venous congestion with massive fluid sequestration and severe oedema, resulting in arterial compromise.