A 30 year old black African Christian missionary lady presented to our accident and emergency department with a mildly swollen left arm. She had left Liberia 11 months before coming to the UK and had been in this country for two months. Her first attendance was a GP referral to the medical on call team. Complaints were an itchy left arm, which had become red over a month. Her symptoms had not resolved with antihistamines or other medication for allergy. There were no other symptoms at this time and she appeared well with no lymphadenopathy or neurovascular deficit in the affected arm. Her breast and chest examination were normal as was her chest radiograph and on investigation there was a mild eosinophilia. All other blood tests were normal including a malaria and sickle cell screen. A working diagnosis of an axillary vein thrombosis was made. She was given low molecular weight heparin while an ultrasound scan was arranged. She was well and the physicians discharged her with outpatient follow up. The next day she attended casualty with pain …