A new or overlooked finding of varicose veins: Ecchymosis

Manifestations of varicose veins include aching, itching, restless leg, edema, muscle cramps, leg ulcers, tightness, and heaviness. In spite of a thorough clinical assessment and duplex scanning, many patients with varicose veins have leg symptoms that are medically unexplained. ¹

A 35-year-old female presented with a several week history of night-time muscle cramps and ecchymosis on both legs. She specifically noticed that the ecchymotic areas would appear the day after nocturnal muscle cramping. A detailed history failed to reveal systemic disease, recent infection or malignancy. She denied using anti-platelet or anticoagulant medications. Her physical examination was normal except for telangiectasias and varicose veins (Panel A-1) on both lower extremities with surrounding irregular ecchymotic patches in different stages of evolution with brownish, pink, or deep purple discoloration (Panels A-2, A-3, and A-4, respectively). Her biochemical and hematological laboratory analyses were normal. Venous duplex ultrasound examination revealed dilatation of great saphenous vein (9 mm in diameter) and retrograde flow >1 second. She was subsequently treated with micronized purified flavonoid fraction. At 1-month follow-up, she was asymptomatic and without ecchymotic lesions on her extremities.

OPEN IN VIEWER Panel A.

Although this is the first reported case of ecchymosis associated with nocturnal leg cramps and varicose veins, presumably this is not the first case in clinical practice. Since the patient was otherwise healthy and micronized purified flavonoid fraction completely relieved her manifestations, we can assume her ecchymotic patches were mediated by superficial venous hypertension. Erythrocyte extravasation during muscle cramp-associated superficial ectatic vein rupture is the most likely mechanism of ecchymosis. A more individualized, detailed history of complaints and reappraisal of venous manifestations is warranted. ² Inclusion of ecchymosis in association with muscle cramps could potentially increase the diagnostic accuracy of venous leg symptoms, although additional corroborative clinical studies are needed.