74-year-old male presented to the emergency department with complaint of fever, weakness, and fatigue and was admitted to the hospital for further workup. The patient was found to have gram negative bacteremia and Clostridioides difficile infection. Computed tomography imaging of the abdomen and pelvis was obtained and demonstrated air in the retroperitoneal/ presacral space tracking to the left hemipelvis and femoral joint. Concern for possible septic joint lead to an Orthopedic surgery evaluation and magnetic resonance imaging of the left hip and pelvis which revealed a complicated perirectal infection tracking to the left hemipelvis. The patient was taken to the operating room with colorectal surgery for further management and treatment.

This case is of a young female with a large uterine leiomyoma causing phlegmasia cerulea dolens with thrombosis of the left common and left external iliac veins. She underwent mechanical thrombectomy to temporize the condition until she could be evaluated by gynecology-oncologist to remove the cause of venous obstruction. Prior to hysterectomy, suprarenal inferior vena cava filter was placed. Less than 12 hours post hysterectomy she developed recurrent thrombosis involving the left common and external iliac veins. She underwent repeat mechanical thrombectomy with wall stent placement in the left common iliac vein with resolution of her symptoms.