Description

A 63-year-old obese man presented with worsening lower leg oedema, fever and chills. Physical examination revealed non-pitting oedema and hyperkeratotic papulonodules with a verrucose appearance in lower extremities, especially at posterior tibial side (figure 1). Oedema sites were warm and red. He had a history of colon cancer treated 8 years ago with surgery and radiotherapy to the lower abdomen. Chronic lymphoedema developed after radiotherapy in both lower extremities (figure 2). He had multiple hospital admissions due to cellulitis related to lower leg oedema. He was treated with intravenous antibiotics and discharged with recommendations of elevation of the limbs and wound care.

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Figure 1

Left ankle and posterior tibial area.

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Figure 2

Chronic lymphoedema in lower extremities.

Elephantiasis nostras verrucosa is a rare, disfiguring complication of longstanding chronic lymphoedema.1 It is characterised by marked oedema of the affected extremity, generalised thickening and lichenification of the skin.2 Disruption of the lymphatic system after trauma, surgery or radiation is the most common cause of chronic lymphoedema. Recurrent soft tissue infections also induce fibrosis and worsen the condition.3 Congenital, traumatic or surgical disruption of lymphatic vessels, venous stasis, radiation, neoplastic obstruction, portal hypertension, obesity and congestive heart failure are the precipitating factors of this disease.2 ,3 The diagnosis is based on the history and the peculiar skin changes. Treatment options include use of elastic bandages, pneumatic stockings, mechanical massage, oral retinoids and surgery. The goal of the therapy is to re-establish function and to reduce physical disability. Oral retinoids were used successfully in some case series. For refractory cases, microsurgical lymphovenous anastomosis can be used. Amputation should be the last option.