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A 77-year-old woman, immobile due to advanced rheumatoid arthritis, presented to the emergency department with a 3-day course of a progressively painful and purple left lower extremity (Fig. 1a). On examination, the limb was discolored, swollen, warmer than the right leg, and very tender. The distal pulses were entirely absent, and only a faint left femoral pulse was palpable. Phlegmasia cerulea dolens (from Latin for inflamed, blue, and painful) was the clinical impression [1] and confirmed with Doppler ultrasound, which demonstrated an occlusive thrombus in the left femoral vein. Sensation and motor function of the limb remained intact. She was started on a heparin drip, and brought to interventional radiology for endovascular therapy. Fig. 1b shows a venogram of the left iliofemoral segment with extensive occlusive deep venous thrombus (DVT) that extended to the left popliteal vein (not shown).Catheter directed lysis was performed overnight resulting in Dopplerable distal pulses and improved symptoms; however, interval venography (not shown) revealed significant residual thrombus burden. The digital subtraction venogram of the left iliofemoral segment in Fig. 1c depicts improved patency and flow following subsequent endovascular mechanical thrombectomy. Fig. 1d shows the improvement in the patient's left leg 12 h later (36 h after presentation). Her pain resolved, and her distal pulses became palpable. She was discharged on warfarin. Although prolonged immobility was the presumptive risk factor for her, consultation with a hematologist/oncologist

A 27-year-old man attending the dermatology clinic for the management of psoriasis complained of severe bilateral hip pain of recent onset. Psoriasis vulgaris affected 15% of his body surface for which he was applying a combination of topical corticosteroids obtained from two separate physicians (0AE05% betamethasone dipropionate 100 mL, mometasone furoate 0AE1% cream 30 g and betamethasone valerate 0AE1% cream 65 g every month). Plain radiography of the hips demonstrated minor flattening of the superior aspect of the left femoral head and a normal right hip. Magnetic resonance imaging (MRI), T1 weighted images, demonstrated areas of isointense necrotic bone surrounded by hypointense revascularization in the collapsed superior aspects of both femoral heads ( Fig. 1) consistent with a diagnosis of stage III osteonecrosis of both femoral heads. This association is extremely rare, but systemic effects of potent topical corticosteroids are increasingly recognized.Osteonecrosis should be considered as a cause of new-onset hip joint pain or limitation in patients using long-term potent topical corticosteroids, particularly in combination. Plain radiography is insensitive in the early stages of disease and MRI is the imaging modality of choice. Figure 1. Magnetic resonance imaging, T1 weighted image, coronal view of pelvis. The superior aspect of the left femoral head consists of an irregular isointense area of necrotic bone that has undergone moderate collapse. There is a hypointense band inferior to this which is a revascularization front consisting of resorption proximal to the necrotic bone and bone formation distally. There are bilateral ring lesions consisting of necrotic bone surrounded by reparative tissue. There is also a small degree of collapse of the superior aspect of the right femoral head.

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