A Female Teen with Swollen Feet
A 10-month history of progressive swelling below the knee makes this 12-year-old's case an ideal stop on the medical mystery tour.
Dr Jon's Medical Mystery Tour: Third Stop
Remember "turfing?" Sending off a case you couldn't diagnose to another service or specialty? What happens if you're not even sure who to turf to?
A teenager with swollen lower extremities isn't common in any practice. Without an obvious cause, the situation could lead to some stress. See what you think.
A 12-year-old girl presents with lower-leg and foot swelling of 10 month's duration, left side more pronounced than the right.
History:
inpatient 3 months ago for fever, infection of R foot. No significant PMH. Swelling is uncomfortable, not painful.
Physical exam:
firm, pitting edema both lower extremities; not painful. Normal growth, menarche; no thyromegaly; normal cardiac exam.
Lower extremities:
The left lower extremity appears slightly more puffy than the right side.
Prominent pitting edema.
Appropriate labs are ordered, follow up scheduled for one week. What are causes of swollen legs in children and adolescents?
Lab results:
Normal SMA - 23; normal thyroid function; normal urinalysis... no protein;normal CBC; negative ANA
Re-cap: 12 year-old female with gradual painless onset of swollen legs; PMH noncontributory; screening labs normal.
Reminder:
In absence of other causes, lymphedema is most common cause of leg swelling in children and adolescents.
Swollen leg, etiology:
General-eg, cyclic edema, CHF, hepatic cirrhosis. Lymphatic-primary or secondary lymphedema.
Swollen leg, etiology:
Venous- deep venous thrombosis, chronic venous insufficiency. Misc-eg, infections, ischemia, vascular anomalies, tumors
Clues to lymphedema diagnosis:
slow, progressive onset; pitting edema; rarely painful but uncomfortable; skin changes; distal origin.
Potential etiologies, primary lymphedema:
Milroy disease, Meige disease Lymphedema praecox, lymphedema tardum, lymphangiomas
Diagnosis:
Late-onset lymphedema, Meige disease, aka, lymphedema praecox; painless onset of soft pitting edema of foot or ankle; female predominance
Pathogenesis:
maldevelopment of lymphatics + increased capillary permeability, increased protein + higher oncotic pressure, incr fluid absorption into interstitial space.
Many known causes;
Trauma, malignant disease, filariasis, infections/inflammations, radiation exposure. All ruled out in our patient.
Where is lymphedema treated?
Not recognized specialty; university hospitals/medical centers have lymphedema clinics, comprehensive, multidiscliplinary services.
Supportive measures: Diuretics, massage, Jobst stockings, skin care, surgery, medication.
Noninvasive complex lymphedema therapy (CLT) - 80% effective
Potential long-term complications: Lymphangitis, cellulitis, lymphangiosarcoma (very rare)
Patient disposition:
treated at a lymphedema center; CLT improved swelling; eventually was moved with the military but was able to locate a lymphedema clinic nearby.
The Mysterious Case of the Girl with Swollen Feet is the third in October’s 4-part Medical Mystery Tour Special Report by Dr Jonathan Schneider.Swelling in the lower extremities in a child or adolescent is an uncommon presenting symptom. Dr Schneider had a hard time with this one and probably considered "turfing" it at one point. A review of original physical findings followed by a more detailed physical examination in this case provided the clues to a diagnosis.Sometimes when you're ready to turf the case but don't know which direction to send it, you can shift from being the "turfer" and get stuck as the "turfee." Be careful.Dr Schneider is a primary care physician with special interests in dermatologic disease and adolescent medicine. When you've complete this case, visit our large collection of his other intriguing cases.Scroll down for resources.
