DVT or Baker's Cyst? Leg Swelling and D-dimer of 7,000

Author: V. Dimov, M.D.; B. Alnemr, M.D.
Reviewer: S. Randhawa, M.D.

An 82-year-old African American female (AAF) is admitted to the hospital with a chief complaint (CC) of lower extremity swelling for one week. It is bilateral and progressive. She denies any injury or trauma, chest pain or shortness of breath (SOB).

Past medical history (PMH)

Hypertension (HTN), osteoarthritis (OA), gout, hyperlipidemia (HLP).

Medications


HCTZ (hydrochlorothiazide), Zocor (simvastatin), Norvasc (amlodipine).

What is the most likely diagnosis?

Deep venous thrombosis (DVT)?
Cellulitis? But there is no fever.
Congestive heart failure (CHF)? But this is less likely without SOB, dyspnea on exertion (DOE) or paroxysmal nocturnal dyspnea (PND).

Where do you want to focus on physical exam?

Neck for jugular vein distention (JVD).
Chest for crackles.
Leg exam for pitting, erythema, pain, signs of infection.
Decreased mobility - is there a fracture?

Physical examination

VS 37.1-12-112-162/79.
WD/WN in NAD.
HEENT: no JVD.
Chest: CTA (B).
CVS: Clear S1, S2.
Ext: 1+ pitting edema (B), good pulses, no evidence of infection or fracture.

What labs would you order?

CBCD, CMP.
The ER doctor also ordered D-dimer.

K+ came back 6 mEq/L!
Relax, BUN/Cr were normal. Also, check the detailed lab report - it was a hemolysed sample and that is why K+ was high. The repeated K+ was 4.4 mEq/L (normal).

D-dimer was positive at 7073. Uric acid 7.3 mg/dL.

What to do now?

The patient was admitted to a regular medical floor (RMF) for further evaluation and to rule out (r/o) DVT.

A lower extremity (LE) duplex ultrasound and X-rays of the lower extremities were ordered.

Would you start Lovenox (enoxaparin) SC or Heparin IV for the presumptive diagnosis of DVT?

What happened?

Now, there is the surprise.

The duplex ultrasound "ruled out" DVT but showed something else - a ruptured Baker's cysts. This was the reason for the LE swelling.

Report of bilateral venous duplex exam


The common femoral, superficial femoral, popliteal, calf veins, and proximal greater saphenous veindemonstrated complete coaptation with compression maneuvers. There is normal response to augmentation and respiratory maneuvers. Of note, the venoussignal is somewhat pulsatile in nature. Also noted is bilateral Baker's cysts which were somewhat lobular in character.

Impression: 1. Negative study for acute DVT of the lower extremities bilaterally; 2. Mildly pulsatile venous flow suggesting hypervolemia; 3. Bilateral Baker's cysts are present as described above. Clinical correlation is recommended.

LE X-rays


Tissue swelling; R knee OA (click to enlarge the images)


R knee OA - cysts, subcortical sclerosis; Close-up view (click to enlarge the images)


OA seen on the lateral XR of the knee (click to enlarge the images)

Report of X-ray knee complete (4+ views) bilateral

Findings: There is severe narrowing of the medial, lateral and patellofemoral joint compartments consistent with osteoarthritis ofthe right knee. Extensive spurring surrounds the right knee joint. No acute fracture or joint effusion is identified.

There is severe degenerative narrowing of the meal, lateral patellofemoral joint compartments of the left knee joint consistentwith osteoarthritis . Extensive spurring projects a posteriorly. No acute fracture or joint effusion is notified.

Final diagnosis

A ruptured Baker's cyst.

What did we learn from this case?

Not all leg swelling is due to the "big three" diagnoses, CHF, DVT, or cellulitis.

Among all patients with leg swelling and pain, the cause is DVT in 20%, cellulitis in 19% and a ruptured Baker's cyst in 9%.

Baker's cyst is an extension of the inflamed synovia to the popliteal fossa.

Baker's cyst is a known association of RA but the most common causes of the cyst are OA and gout simply because these 2 conditions are much more common than RA.

Treatment is supportive and NSAIDs.

References

eMedicine, AFP
What is fabella? - FP Notebook
Oral rivaroxaban is non-inferior to standard therapy for symptomatic pulmonary embolism (PE) and DVT (NEJM, 2012).

Published: 01/12/2004
Updated: 03/12/2012

6 comments:

  1. Can you have the baker's cyst taken out? Especially, if it is
    more than one.
    THank you

    ReplyDelete
  2. I have also been having a problem with my left knee two years after total knee replacement. Five times in the last three months it has blown up on me, and I am hoping there is a way to get rid of the cyst so as to keep it from recurring. Very painful and rather difficult to diagnose. Looking for more info on the subject and came upon this website. Thanks for the great information.

    ReplyDelete
  3. My wife has a bakers cyst and had it reciently drained having had much fluid. A few weeks later it is back and she can feel it filling up again. Is there anything that can be done to keep the cyst from filling up again or reoccuring without any knee surgery at this time. It is bad timing due to her occupation!

    ReplyDelete
  4. I have been dealing with a baker's cyst which is somewhat tangled with my knee and extends down into my calf. It had limited my ability to be active and sometimes swells to the point that I can neither straighten it or bend it. Recently I was also diagnosed with DVT in the same leg lower down from the cyst. As I have been told by several doctors, my cyst is undrainable because it is full of thick fluid. Therefore the chances of it breaking and going away are extremely small if any. I am 26yrs old...can I live with this cyst forever..? What other options are there? My whole body alignment is out do to overcompensation and I am now having to see a physiotherapist(not cheap) is surgurey my best bet?

    ReplyDelete
  5. i have a big baker cyst on my right leg the swelling is so bad that i cant even walk my leg turn reddish blue my feet are all swelling too when to the doctor and the only thing they keep telling me is i have a large baker cyst in the back of my knee and there is nothing they could do about it ....now my left leg it 's all swelling and the pain it so bad cant sleep at night and cant walk anymore everything i read about baker cyst it is not what i am feeling what can i do

    ReplyDelete
  6. I would see an orthopedist or rheumatologist if I were you.

    ReplyDelete