Solomon Sallfors

Ambulatory Morning Report: Leg swelling

Chief Complaint: 50 year old African-American woman presents with left leg swelling for 5 years.
HPI: Patient presents for management of chronic lymphedema of her left leg, which began 5 years ago
following a spider bite. Patient claims to have witnessed the spider bite. The leg swelled with 24 hours. At the
time, it was warm and erythematous. Patient was treated at the time with multiple antibiotics, including
vancomycin, rocephin, and clindamycin. Patient has been seen multiple providers over the years, and the
swelling has gotten progressively worse. Swelling does not resolve with elevation. Today, her leg is swollen
from the knee down, cool, non-erythematous and non-tender. Recently, patient had US and CT scan to
investigate lymphedema (see below). On review of systems, she reported severe night-time sweating, vaginal
discharge, dysuria, chlamydial infection 6 mos ago (clindamycin), partner non-treatment, prior STDs, prior
STDs in partner.
PMHx: None other than in HPI. FMHx: None relevant. Surgeries: None. Allergies: NKDA. MEDS: none.
Social: Disabled, no recreational drugs, poor socio-economic condition.
ROS: Neg. except as in HPI, including no rash, chest pain, shortness of breath, focal neurological complaints,
history of arthritis, connective tissue disease, diabetes, neuropathy, or prior trauma.
PE: VITALS: 120/80, 70bpm, O2 sat 100% on room air, 98.5 temp, 18 Resp.
Gen: Awake alert and reasonably cooperative. Patient is well kept and appropriately dressed. Insight and
judgment intact but guarded.
Abdomen: Tender RLQ. Bowels sounds in all 4 quadrants.
Musculoskeletal: Normal size, tone, and ROM of major muscle groups. Major joints are non-tender, cool, and
non-eryuthematous.
Neuro: 5/5 muscle strength UL and LE major muscle groups, 2/4 deep tendon reflexes.
Extremeties: Left leg is swollen from the knee down, cool, non-erythematous and non-tender. Skin appears
fibrotic, congested, soft, without streaking. Unable to find pedal and post tibial pulses on left. Cap refill <2 secs
both LE. >5 cm difference in circumference in left leg over right.
Urogenital/pelvic: Cloudy white discharge throughout vagina. Neg chandelier sign. Tenderness in right adnexa.
Foul odor.
Other systems: neg.
LABS: Pending vaginal culture.
IMAGING: CT Abd and Pelvis: enlarged uterus and right ovarian cyst. US similar findings.
DDx:Primary lymphedema: congenital defects (neurofibromatosis type 1 and Proteus syndrome)
Secondary lymphedema: filariasis due to Wuchereria bancrofti (central Africa, the Nile Delta, Turkey, India,
the East Indies, Southeast Asia, Philippines, Oceanic Islands, and parts of South America), post-cancer/postradiation,
Dx: 1. Vaginitis, possibly PID. 2. Lymphedema, unknown etiology.
Treatment/Workup: Pelvic exam with culture. Patient elected not to take empiric antibiotics prior to culture
results.
Definitions: Lymphadenitis: inflammation of lymph nodes
Lymphangitis: inflammation of lymph vessels
Lymphedema: localized fluid retention and tissue swelling caused by a compromised lymphatic system.
Grades by severity (referenced against healthy extremity)

Solomon Sallfors

Grade 1 (mild edema): involves distal parts such as a forearm and hand or a lower leg and foot. The
difference in circumference is less than 4 cm, no other tissue changes.

Grade 2 (moderate edema): involves an entire limb or corresponding quadrant of the trunk. Difference
in circumference is >4 but <6 cm. Tissue changes.

Grade 3a (severe edema): Lymphedema is present in one limb and its associated trunk quadrant. The
difference in circumference is greater than 6 centimeters. Significant skin alterations, such
as cornification or keratosis, cysts and/or fistulae, are present. Additionally, the patient may experience
repeated attacks of erysipelas.

Grade 3b (massive edema): same as grade 3a, except two or more extremities are affected.

Grade 4 (gigantic edema): called elephantiasis, almost complete blockage of the lymph channels.
Staging (International Society of Lymphology, meant to improve diagnosis and outcome). This involves two
criteria to diagnose and classify lymphedema: the "softness" or "firmness" of the limb (reflecting fibrotic soft
tissue changes) and the outcome after elevation:
Stage 0: subclinical or latent, swelling is not evident despite impaired lymphatic transport, most
asymptomatic, with heaviness in the limb. months or years.
Stage I - accumulation of fluid that subsides with 24-hour limb elevation, soft edema that may pit, with
no evidence of dermal fibrosis. Usually upon waking in the morning, the limb or affected area is normal or
almost normal in size. Called reversible edema.
Stage II doesnt resolve with 24-hour elevation, due to dermal fibrosis, non-pitting, spongy consistency,
affected area bounces back w/o indentation. Called spontaneously irreversible lymphedema.
Stage III Called lymphostatic elephantiasis, no pitting, trophic skin changes such as fat deposits,
acanthosis, and warty overgrowths. Tx is surgery, "debulking", risks may outweigh benefits

TX: First-line treatment is physical therapy, aimed at improving lymphedema with manual lymphatic drainage,
massage, and exercise, as well as compression stockings, multilayer bandaging, or pneumatic pumps. Leg
elevation is essential. Surgical treatment is palliative, not curative, and it does not obviate the need for
continued medical therapy. Moreover, it is rarely indicated as the primary treatment modality. Rather, surgical
treatment is reserved for patients who do not improve with conservative measures or for cases in which the
extremity is so large that it impairs daily activities and prevents successful conservative management.
COMPLICATIONS: Lymphangiosarcoma and infections and reduced quality of life
Research Considerations: Chlamydiae have the ability to establish long-term associations with host cells. A
former rickettsial species, and considered an obligate intracellular pathogen and producing elementary bodies,
they can cause chronic epididymitis, chronic prostatitis, Lymphogranuloma venereum, asymptomatic PID, and
in atherosclerotic plaques. Beta lactams have been suspected to cause persistent-like growth state, which can
contribute to the chronicity of chlamydial diseases. Genital elephantiasis or esthiomene, which is the dramatic
end-result of lymphatic obstruction... This is usually seen in females, may ulcerate and often occurs 120 years
after primary infection.i

i Fairley CK, Gurrin L, Walker J, Hocking JS (2007). ""Doctor, How Long Has My Chlamydia Been
There?" Answer:"... Years"". Sexually Transmitted Diseases 34(9): 7278.