Case Report

Superficial Venous Thrombosis Presenting asa Painful Popliteal Fossa Mass in a Child

Dianna M. E. Bardo, MD, Kimberly E. Applegate, MD, Marilyn J. Goske, MD, Thomas E. Kuivila, MD,Johanna Goldfarb, MD

The Cleveland Clinic Foundation and Children’s Hospital, 9500 Euclid Avenue, Cleveland, Ohio 44195

Received 2 March 1998; accepted 12 June 1998

ABSTRACT: We report an unusual case of superficialvenous thrombosis in a cyanotic 12-year-old childwho had undergone recent appendectomy. Althoughcompression, color Doppler, and duplex ultrasoundtechniques remain the keys to the diagnosis of venousthrombosis, SieScape sonography was beneficial indemonstrating the extent of the thrombi and their lo-cation along a superficial thrombosed vein. © 1998John Wiley & Sons, Inc. J Clin Ultrasound 26:470–473,1998.

Keywords: superficial venous thrombosis; thrombo-sis; popliteal fossa mass; children; ultrasonography,extended field-of-view

Virchow first described thrombosis and hy-pothesized a number of etiologies including

disrupted blood flow, disrupted venous epithe-lium, and hypercoagulopathy, alone or in anycombination.1 The diagnosis of venous thromboticdisease accounts for a significant portion of thetime and expertise in hospital ultrasound depart-ments.2 The diagnosis of deep vein thrombosis isusually made using compression, color Doppler,and duplex ultrasound imaging techniques. Su-perficial venous thrombosis is often diagnosedclinically when a tender, palpable cord is felt inthe distribution of the saphenous venous system.We present a case of popliteal fossa superficialvenous thrombosis in a 12-year-old girl with con-genital heart disease who presented with a pain-ful popliteal fossa mass, which mimicked a hem-orrhagic Baker’s cyst or lymphadenitis. The

imaging of this patient’s superficial venousthrombosis was enhanced with the panoramicviews obtained with extended-field-of-view(SieScape) technology (Siemens Medical Systems,Iselin, NJ).

CASE REPORT

The patient was a 12-year-old girl who had amedical history significant for cyanotic congenitalheart disease with Eisenmenger’s syndrome.Seven days prior to presentation, she developedright lower quadrant pain and underwent appen-dectomy. Although her appendix was normal, theabdominal pain resolved spontaneously. Therewas no history of central venous catheterization.On postoperative day 7, she presented with a 2-day history of left popliteal fossa pain, localizedswelling, and fever, without a trauma history.Hemorrhage into a Baker’s cyst was suspected,and sonography was requested.

Ultrasound examination was performed usinga 7-MHz transducer (Siemens Elagra; SiemensUltrasound, Issaquah, WA) and extended-field-of-view (SieScape) technology. SieScape ultrasoundimages demonstrated 4 oval, hypoechoic, 0.5–2.0-cm masses in the deep subcutaneous tissue of theleft popliteal fossa, oriented in a craniocaudal di-rection along a hypoechoic cord (Figure 1). Bloodflow was not demonstrated within the cord or themasses (Figure 2). The deep venous system wasnormal bilaterally. The differential diagnosis in-cluded superficial venous thrombosis and lymph-adenitis; sonography excluded the possibility of ahemorrhagic Baker’s cyst.

Laboratory values for platelet count, core co-agulation profile, hypercoagulation panel (pro-

Correspondence to: D. M. E. Bardo, Department of RadiologyHb6, The Cleveland Clinic Foundation, 9500 Euclid Avenue,Cleveland, OH 44195

© 1998 John Wiley & Sons, Inc. CCC 0091-2751/98/090470-04

470 JOURNAL OF CLINICAL ULTRASOUND

teins C and S, antithrombin III, plasminogen, andactivated protein C resistance), plasma homocys-teine, and serum iron were normal. A blood cul-ture was negative. The family history was nega-tive for thrombosis or varices.

Because of her persistent fever, relative in-

crease in white blood cell count, and recent his-tory of unexplained abdominal pain, surgical re-section of all of the masses was performed.Pathologic examination of the surgical specimenshowed acute venous thrombosis and varices,without evidence of infection or tumor.

FIGURE 1. Sagittal SieScape image obtained using a 7-MHz linear transducer shows several hypoechoic, oval masses in the left popliteal fossa(large arrow) tethered by a hypoechoic cord (small arrow). The largest measured 1.9 × 1.2 cm.

FIGURE 2. Power Doppler sonogram shows some flow around the thrombi. There are no color signals inside the masses.

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Further investigation of the pelvic and lowerextremity venous anatomy with MR venographydemonstrated normal flow in the inferior venacava and common iliac and external iliac veins.There was no signal in the contralateral internaliliac vein, suggesting the presence of an anatomicvariation. MR images of the abdomen and pelviswere unremarkable. The patient was dischargedthe following day without further treatment. Shehas not had further sonography but has beenasymptomatic on clinical follow-up for 1 year.

DISCUSSION

Superficial and deep venous thrombosis are com-mon clinical and sonographic diagnoses in adultsbut are considered less frequent in children.3,4

Venous thromboses are manifested as varicositiesof the superficial system in 90% of cases.5,6 Theprogression of thrombotic disease from the super-ficial to deep veins or vice versa cannot usually beestablished. 5,7

Superficial venous thrombosis can occur sec-ondarily to or as the primary cause of varicoseveins. Primary varicose veins in the lower ex-tremity develop as the result of superficial valvu-lar incompetence, which may be hereditary8,9; afamilial association has been documented in a re-cent French study of 134 families.9 Secondaryvaricose veins result from valve failure or valvedamage caused by reflux of blood from the deepveins to the superficial system.

The risk of venous thrombosis is increased sig-nificantly in children with central venous cath-eters.10,11 Neonates with central venous cathetersare at greatest risk of thrombosis, accounting for50–80% of cases of neonatal venous thrombosis.10

Older children, even in the intensive care unitsetting, are at a significantly lower risk for throm-bosis than are adults in the intensive care unit.

In the absence of central venous catheters, 3 ormore risk factors are generally needed beforethrombosis occurs in children.4,12,13 Additionalrisk factors include genetic conditions such assickle cell anemia, protein C or S deficiency, orinherited coagulopathies and nongenetic condi-tions such as malignancy, autoimmune disorders,iron deficiency anemia, major trauma, renal dis-ease, oral contraceptive use, postoperative stasis,and infection.12,13

Surgical procedures such as appendectomy arenot usually associated with an increased risk ofvenous thrombotic disease in children.13,14 Post-

surgical thromboembolic complications have beenreported, however, when thrombocytosis and anadditional risk factor, such as cyanotic heart dis-ease or cardiac arrhythmia, were present.10,14,15

Our patient had a negative family history forvenous thrombosis, and there was no evidence ofgenetic risk factors for thrombotic venous disease.The patient was prepubescent and had no historyof central venous catheter placement. Her historyof cyanotic heart disease with Eisenmenger’s syn-drome in combination with the recent surgerymay have precipitated superficial venous throm-bosis in 1 leg.

In this unusual presentation of superficial ve-nous thrombosis in a 12-year-old child that ini-tially mimicked a hemorrhagic Baker’s cyst orlymphadenitis, SieScape sonography was usefulin demonstrating the location of the thrombosedvarices along a thrombosed superficial venouscord.

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11. DeAngelis GA, McIlhenny J, Willson DF, et al:Prevalence of deep venous thrombosis in the lowerextremities of children in the intensive care unit.Pediatr Radiol 1996;26:821.

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