Unilateral cutaneous congestion induced by Valsalva manoeuvre due to vascular malformation.

To cite: Hirose K, Hirosawa T, Shimizu T. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2017219625 DESCRIPTION A man aged 37 years presented with hip osteoarthritis with avascular femoral head necrosis due to chronic alcohol use. He had spinal arteriovenous fistula (AVF) which was diagnosed with spinal angiography (figure 1A, B) and spinal MRI (figure 2) 30 years prior. The lesion was not completely treated by surgical intervention at that time. On examination, Valsalva manoeuvre showed a reversible and rapid change in colour of his unilateral chest wall (figure 3A, B and video 1). Contrast-enhanced CT of the chest on the same location revealed cutaneous vascular malformation (figure 4). The dermatome level exactly also corresponded to the dermatome level of spinal AVF. Valsalva manoeuvre can augment neurological symptoms in intraspinal neurological process such as a large disc, tumour or spinal AVF. Symptoms of spinal AVF usually involve leg weakness or paraparesis (96%), sensory numbness or paresthesias (90%), urinary incontinence or retention (82%) and pain (55%). According to the previous report, the spinal cord symptoms were reported to be aggravated and precipitated by Valsalva manoeuvre, trauma, pregnancy, postural changes, increase in body temperature or muscular effort. The finding seen in our patient can be explained by the transient congestion of blood flow induced by rapid increase in intrathoracic pressure by the manoeuvre on top of the cutaneous and spinal anomalous vascular flow.