77 year old J.P. has experienced many years of progressive leg swelling. Her legs always seemed disproportionately larger than the rest of her body.Her primary care physician associated her large legs to her dietary indiscretions, and often described them simply as swollen and edematous. The status-quo continued until one day she presented to our Wound Center with 3+ pitting leg edema, and blistering of her left anterolateral calf. An arterial and venous doppler ultrasound was immediately obtained and showed no deep vein thrombosis or evidence of atherosclerotic occlusive disease. Closer examination of her lower extremities confirmed characteristics consistent with the typical trophic skin changes of secondary lymphedema Note the absence of varicosities, which are often thought to co-exist with chronic venous insuffi-ciency, but frequently are absent. The patient was afebrile and preliminary blood work showed no leukocytosis or bandemia. The erythema noted was consistent with severe stasis dermatitis and not a bacterial infection. Therefore, the patient did not require hospitalization for parenteral antibiotics. A Unna Boot was applied at the time of the patient’s first visit, with resultant rapid and effective reduction in edema, venous hypertension. The Unna Boot was removed after 72 hours and the extremity inspected. The patient responded nicely to treatment, but even after her stasis ulcer had resolved, she still complained of leg heaviness, easily fatigability, and diminished functional capacity. These persistent symptoms were all attributable to her lower extremity lymphedema. Having met all insurance requirements, she was considered a good candidate to start intermittent pneumatic compression therapy. She was well motivated, capable of adhering to a routine. Establishing the diagnosis of lymphedema early in the course of treatment will avoid potential delays in qualifying the patient for beneficial intermittent pneumatic compression (IPC) therapy. The use of IPC therapy complements extremity off-loading through extremity elevation, gradient compression garments and a physical therapy regimen.
The patient should be closely monitored for response to treatment and to insure compliance with the designated care plan.
