Sunday, February 03, 2019

Acute Lymphedema

Presented by Dr. Henry Foong
Ipoh, Malaysia

The patient is a 50-yr-old man with a history of swelling of the right leg for 2 months. He noted that the right foot was swollen initially and a few weeks later the swelling has progressed to the right leg.  Over the past week the swelling has progressed to the right thigh. The swelling was mildly painful but overall the past week the swelling has progressed a lot.  The swelling was so severe that he was unable to wear his normal shoe. He has a history of hypertension and a history of “stroke” where he lost his consciousness and was told by his doctor he suffered from a minor stroke.  He was treated as cellulitis by his doctor with penicillin but did not improve.  In fact he had developed a generalised maculopapular eruptions over the trunk a week after starting on IV penicillin.

O/E: Shows a severe unilateral swelling of the right leg extending from the foot to the thigh.  There was superficial erythema, desquamation with small blisters. The affected areas are well-demarcated especially on right thigh.  The leg swelling was indurated and mildly pitting.  The measured circumference of the right leg at mid-calf level was 51 cm compared with the corresponding left leg of 39 cm.  His right inguinal nodes were markedly enlarged. Rest of exam was unremarkable.

Images: 

Differential Diagnosis
1.  Erysipelas right leg
2.  Filariasis
3.  Deep vein thrombosis

Lab:
Hb 13.5 gm%, TWBC 17,900 (N87%, L10%, E0.1%, B1% M2%) ESR 79mm/hr Biochemistry unremarkable. Culture from the right leg grew Staphylococcal aureus.  Doppler ultrasound right leg did not show any evidence of deep vein thrombosis but enlarged right inguinal nodes.

He was advised to stop penicillin and started on IV moxifloxacin 400mg od, IV hydrocortisone 200mg qid,  and wet compress. Blood was sent for microfilaria (x3) which was negative.

Follow-up Photo after 5 days of IV moxifloxacin and IV hydrocortisone.

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Marked improvement after 5 days of IV moxifloxacin and IV hydrocortisone.  There is a 5 cm reduction in the circumference of the right call. The patient would be scheduled for a MRI lower pelvis/right thigh soon, but he has refused since he is feeling so much better.
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Your thoughts will be appreciated.

3 comments:

  1. Let’s thank Henry for another interesting presentation.

    I think the long duration of two months and the marked lymphoedema suggest more than erysipelas, which should have settled with penicillins given earlier.
    It may be a case of acute dermatolymphangioedema ( ADL) due to bacterial secondary infection on top of filariasis which is still endemic in this part of the world. Blood films are often negative, they have to be taken in consecutive midnights, at least for three nights and repeat if necessary.
    As overt filariasis is common, a good course of dimethylcarbamazine may be agreeable to the patient. The present improvement may be due to the reduction of bacteria which are secondary player?

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  2. From Prof. Sharquie: This is a typical case of extensive erysipelas and received the right therapy .I have seen similar case three months ago in elderly patients

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  3. From Robert Shapiro: I think he had a DVT which resolved after 2 months.

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