CASE REPORT Acute upper arm ischaemia: a rare presentation of non-Hodgkin’s lymphoma Z. J. Daruwalla Æ A. R. A. Razak Æ D. Duke Æ L. Grogan Received: 6 December 2007 / Accepted: 16 July 2008 Ó Royal Academy of Medicine in Ireland 2008 Abstract Digital ischaemia has been sparsely reported in current literature. Its association with lymphomatous con- ditions has been described in even more exceptional occurrences. We present the first case of upper arm ischaemia associated with non-Hodgkin’s lymphoma. A brief literature review of this rare phenomenon is also accompanied with it. Keywords Lymphoma Á Ischaemia Á Chemotherapy Á Radiotherapy Á Limb Á Steroids Introduction Ischaemia of the extremities is a rare presentation of malignant disease. While acute digital arterial insufficiency associated with lymphoma has been cited in three case reports [1–3], we report a rare and first case of lymphoma presenting with acute ischaemia of the upper arm. Case report A 28-year-old male presented acutely with a painful, dusky and swollen left upper arm. There was no preceding history of trauma. The patient had no significant past medical history though did complain of mild exertional dyspnoea the preceding few weeks. Fever, night sweats and rigors were all absent. There was no relevant family history, including bleeding or clotting disorders. On examination, the left upper arm was swollen and markedly larger than the right. It was dusky and purple with fluctuating color. The radial pulse was diminished on the ipsilateral side and was momentarily absent during palpation. These findings were not found to be position dependent. Both brachial and ulnar pulses were palpable and normal. No neurological deficit was noted and the patient had full range of movement in his left arm. There was no cervical lymphadenopathy and Pemberton’s sign was negative. Arterial occlusion was the clinical diagnosis with a queried cause. Full blood count, urea, creatinine, electrolytes and liver enzymes were normal. A thrombophillia screen was also negative. A wide mediastinum was noted on chest X-ray (Fig. 1a, b). An urgent computerized tomography (CT) of the chest demonstrated a large soft tissue mass with central necrotic features arising from the anterior mediastinum, measuring 13 9 12 cm on the longest measurable axes (Fig. 2a). This lesion seemed to encase all the great vessels and the proximal branches of the aorta, including the innominate artery (Fig. 2b), explaining the clinical presen- tation of left upper arm ischaemia. The superior vena cava was also compressed but patent. Further imaging in the form of CT neck, abdomen and pelvis were all normal. Extensive thrombus extending from the brachial vein a few centimetres above the antecubital fossa to the supraclavicular portion of Z. J. Daruwalla (&) Department of Orthopaedic Surgery, Beaumont Hospital, Beaumont Road, Dublin 9, Republic of Ireland e-mail: zubinjimmydaruwalla@rcsi.ie A. R. A. Razak Á L. Grogan Department of Medical Oncology, Beaumont Hospital, Beaumont Road, Dublin 9, Republic of Ireland D. Duke Department of Radiology, Beaumont Hospital, Beaumont Road, Dublin 9, Republic of Ireland 123 Ir J Med Sci DOI 10.1007/s11845-008-0206-3