An 81 year old man presented with an asymptomatic swelling of his left upper limb. The patient's past medical history included angina, hypertension, and a stroke (five years previously) which left him with mild dysphasia, but no other deficit. There was no past medical or family history of thrombosis.

There was a two day history of swelling. The arm was not painful, hot or red, and there was no history of trauma. Apart from pain in the left side of his neck, which had been present for three weeks, the patient was well. System review revealed nothing apart from mild expressive dysphasia.

Examination revealed a non-tender arm, swollen to the elbow. Pulses were present and the skin was normal. No abnormalities were detected on examination of the axilla. A firm immobile lymph node was palpable in the anterior triangle of the neck. Prominent vessels were noted on the anterior chest wall. Examination was otherwise unremarkable. The patient was apyrexial with a blood pressure of 136/55 mm Hg.

Initial investigations revealed a haemoglobin concentration of 147 g/l, a white cell count of 8.8 × 10⁹/l, with an erythrocyte sedimentation rate of 18 mm/hour. His international normalised ratio was 0.9. Chest radiography showed left basal shadowing, and a widened mediastinum. Further investigations included venography (fig 1), computed tomography of the thorax (fig 2) and, on the basis of this, high resolution abdominal computed tomography (fig3).

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Figure 1

Venogram.

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Figure 2

Computed tomogram of the thorax.

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Figure 3

High resolution abdominal computed tomogram.