macadamia813 Posted February 2, 2011 Share Posted February 2, 2011 There was a mention of more case studies, so here I go. I'm going to update as the case progresses. 45 y/o female presented last week with right lower extremity edema X 5 days. No associated injury. No prior surgeries in this area. No pain, paresthesias, color/temp changes to skin. No calf pain. First noticed edema in the shower. Meds: none; no OTC meds PMH: not contributory PSH: One C-section ROS: A complete review of systems was negative. This includes no fever, visual changes, H/A, N/V/D, CP/SOB/palpitations, no urinary/BM changes. SHx: no tobacco/etoh/drugs; no recent travel PE: NAD nontoxic RR S1S2 no MRG CTAB no WRR Abd soft NDNT no HSM LE: 1+ non pitting edema R LE above ankle; measurable calf difference of one inch. Othewerise, bilateral LEs N/V/M/I/E Initial workup: Lower extremity doppler (groin to foot): negative Tib/Fib/Ankle XR: negative Labs: CBC: wnl CMP: wnl UA: wnl TSH: wnl RF: wnl ESR: wnl CRP: wnl ANA: Positive Patient came back today for follow up. I had ordered a lupus/sjogren's/scleroderma antibody panel which turned up negative. I measured the calves again...edema now down to 1/2 inch difference side to side. Checked for lymphadenopathy of groin - none observed. Did pelvic exam...no visible lesions on cervix, no CMT, no palpable pelvic mass on bimanual exam. Only change in patient's symptoms is occasional paresthesia to medial R ankle. So what would you do now? Link to comment Share on other sites More sharing options...
deborah212 Posted February 2, 2011 Share Posted February 2, 2011 Does she have any FMHx of CA or hypercoagulability? What's her neuro exam like? Any evidence of decreased sensation with the intermittent parasthesias? I think I'd CT her abd/pelvis. Otherwise healthy 45 yo female with new onset unilateral edema of unknown cause... my concern would be extrinsic compression of the lymphatic system. Also would like to get a better sense if anything is going on with the right iliac, which would be missed on dopplers. Link to comment Share on other sites More sharing options...
Just Steve Posted February 2, 2011 Share Posted February 2, 2011 I would have no idea where to start on this patient. My first gut reaction is to prescribe some Tincture of Time and adapt a wait/see approach. It's asymptomatic, she has no complaints other than her noticing the difference in size, which has resolved by 50% on follow up. Rule out the obvious dangerous things such as DVT's and such (without obvious pain, color/temp change it would not be my first thought). Consider lymphatic inclusion, maybe an insect bite somewhere, no lymph nodes were palpable though. Lack of elevated WBC/fever, normal energy/appetite levels leads me away from infectious process and/or cancers. My thought on this (I may be wwaayy off course, please bear with me) is that by the time an infection/mass causes visible/palpable changes that are obvious to normal vision and palpation, they have released enough enzymes and byproduct to cause systemic changes that the patient would describe as pain, malaise, case of the "feelz badz". Since she does not present with any other associated sx, I'm at a loss. Granted, she has an elevated ANA so there are autoimmune routes to explore such as RA (already looked for Lupus). There is Felty's Syndrome listed on this website http://arthritis.about.com/od/diagnostic/a/ana.htm but with no splenomegly and a normal WBC, it's hard to go down that road as well. I'm doing down the road of "edema with no evidence of systemic occlusion/infection, consider micro trauma due to prolonged standing or undetected injury sustained during sleep" go easy on me...haven't started school yet Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 2, 2011 Moderator Share Posted February 2, 2011 "my ankle was swollen and my PA did a pelvic......." Can just see the patient trying to link those two things together (I for one am having a tough time with it unless she had soe GI or GU complaints) Negative US does not R/O a DVT (yes/no) Which leg is more common to get swelling with CHF? (L or R) What is the findings of DVT? Does she cross her legs? (mechanical obstruction of flow) "tincture of time" might be just the thing..... Link to comment Share on other sites More sharing options...
deborah212 Posted February 2, 2011 Share Posted February 2, 2011 I was impressed with the pelvic... I believe the thought process was to assess for possible malignancy (cervical/ovarian) given her age that could explain unilateral ?lymphedema. Good thought about leg-crossing. Better question than me exposing her to oodles of radiation. :) Link to comment Share on other sites More sharing options...
eze8923 Posted February 3, 2011 Share Posted February 3, 2011 hrm, what does she do for work? recent changes in lifestyle? i like the leg crossing idea as well... vitals? body habitus? skin manifestations/findings? non-contributory PMH? would've thought may thurner syndrome, but it's left sided. don't know what to make of that ANA though in any case. will keep on pondering away... Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted February 3, 2011 Share Posted February 3, 2011 I'd like a neuro exam also now that the parasthesias have developed. Any decreased DTR's/sensation? I can't think of any neuro issues that would cause edema. My first thought was a problem with the lymph system, but at this point I don't think DVT can be ruled out. Link to comment Share on other sites More sharing options...
andersenpa Posted February 3, 2011 Share Posted February 3, 2011 If this is really non pitting edema, it is likely lymphedema, not hydrostatic edema seen with venous obstruction (again IF it is non pitting) Unilateral things are local. Medial ankle is L4, saphenous nerve. Link to comment Share on other sites More sharing options...
laarnie1231 Posted February 3, 2011 Share Posted February 3, 2011 I agree with AndersenPA. If it's really non-pitting edema, it's more likely lymphedema. How was her skin (esp on the site of edema) looks like? I was also looking towards her thyroid function which can suggest a pretibial myxedema but the TSH was normal. Any recent travel for any possible bites? If not, we can always look into her kidney and cardiac function. Link to comment Share on other sites More sharing options...
andersenpa Posted February 3, 2011 Share Posted February 3, 2011 I agree with AndersenPA. If it's really non-pitting edema, it's more likely lymphedema. How was her skin (esp on the site of edema) looks like? I was also looking towards her thyroid function which can suggest a pretibial myxedema but the TSH was normal. Any recent travel for any possible bites? If not, we can always look into her kidney and cardiac function. In general, unilateral is local and systemic disease is bilateral Link to comment Share on other sites More sharing options...
macadamia813 Posted February 3, 2011 Author Share Posted February 3, 2011 So I had talked with my SP about the case and he came in to see her as well. He was the one who suggested the pelvic exam (can't give myself the credit). I did NOT do the pelvic exam on the first visit, but the follow up visit when the pieces of the puzzle weren't coming together. My SP talked with her as well. We are doing an abdominal/pelvic ultrasound to start. Although if we were looking for an occult mass, it would probably be better to go ahead and do the CT abdomen/pelvis right off the bat. As a few of you suggested a more "watch and wait" approach - that had been my initial thought. I suppose we'll see if anything shows up on the U/S and go from there. More info about the patient: Vital signs wnl Body habitus: thin, tall Crossing legs: not sure - maybe I'll ask her about that! No recent travel/ no bug bites No Fam Hx of hypercoagulability No change to neuro exam of lower extremity Someone mentioned not being able to rule out the DVT with the doppler (meaning it could be higher up in the vascular tree). Any thoughts on looking at a D-dimer? Link to comment Share on other sites More sharing options...
macadamia813 Posted February 3, 2011 Author Share Posted February 3, 2011 I have to apologize - it is actually the LEFT lower extremity. My bad. I mis-spoke. So May-Thurner...a friend of mine did a case report on that in PA school so I am somewhat familiar with the syndrome. I'll be reading up on that... Link to comment Share on other sites More sharing options...
deborah212 Posted February 3, 2011 Share Posted February 3, 2011 I have to apologize - it is actually the LEFT lower extremity. My bad. I mis-spoke. So May-Thurner...a friend of mine did a case report on that in PA school so I am somewhat familiar with the syndrome. I'll be reading up on that... Interesting...Like eze8923, May-Thurner popped into my mind (saw it several years ago) but didn't think it was the cause here given the right-sided edema. If this persists, all the more reason to get a look at her iliacs. Link to comment Share on other sites More sharing options...
marilynpac Posted February 3, 2011 Share Posted February 3, 2011 Pretibial myxedema is pitting edema...I had it. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted February 3, 2011 Administrator Share Posted February 3, 2011 Pretibial myxedema is pitting edema...I had it. Unliaterally, though? Link to comment Share on other sites More sharing options...
marilynpac Posted February 3, 2011 Share Posted February 3, 2011 Unilaterally???? No.... Link to comment Share on other sites More sharing options...
sbellin Posted February 4, 2011 Share Posted February 4, 2011 The ANA being positive without a ratio is useless and could be a red herring. A d-dimer would be of little or worse value at this point. The money so to speak is in the pelvis. I did'nt see her body habitus mentioned. An generous abdomen can hide alot of pelvic pathology. Scan her. Link to comment Share on other sites More sharing options...
macadamia813 Posted February 4, 2011 Author Share Posted February 4, 2011 I had mentioned the body habitus was thin/tall (probably has a BMI of 19-20). ANA ratio was 1:320 I believe. Looking to get results of the abdominal/pelvic U/S today or Monday. Link to comment Share on other sites More sharing options...
deborah212 Posted February 4, 2011 Share Posted February 4, 2011 I had mentioned the body habitus was thin/tall (probably has a BMI of 19-20). ANA ratio was 1:320 I believe. Looking to get results of the abdominal/pelvic U/S today or Monday. I was surprised by the ANA titer. Do you know what the pattern was? ... but still don't think it's autoimmune because of the unilaterality. Doesn't sound like she has any dematologic findings of vasculitis. Does shes have any symptoms of rheumatologic disease? I believe there's an association with +ANA and malignancy, particularly NHL. Hopefully that's not the case here. Could just be a red herring as sbellin mentions. Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 5, 2011 Moderator Share Posted February 5, 2011 The ANA being positive without a ratio is useless and could be a red herring. A d-dimer would be of little or worse value at this point. The money so to speak is in the pelvis. I did'nt see her body habitus mentioned. An generous abdomen can hide alot of pelvic pathology. Scan her. Yikes slow down their skippy... abd/pal CT is something in the neighborhood 30 mSv and carreis a moderate lifetime risk of develping a CA! - That is a LOT of radiation in this case where you have very little to go on. (check out http://www.radiologyinfo.org/en/safety/index.cfm?pg=sfty_xray) for more info..... we all are to quick to get a CT these days to the core/torso and head..... I would think that a really good knee exam is in order and maybe even another US to specifcially look for baker's cyst - have seen MANY times a Bakers get so big (and maybe rupture) that it impedes (sp?) lymphatic flow. As well plantaris ruptures will give almost same type of swelling (but usually with the patient saying at some point they had some discomfort) I would NOT step to a CT right now with out some type of hard facts to support it - it would be better to refer to someone else - ie heme or physiatiry they give this 45 yr old female a radiation exposure and a dye load (hope you don't cause ARF or CRF! - yes I have seen a baseline worsening - Cr increase by 0.5 - a few times in young healthy people getting dye loads.) and I would put just about no weight on a the ANA with normal ESR and CRP (was it HS or normal CRP?) I would get a D-Dimer before doing a CT but I would do another US before either of those - like any study or test US is not 100% - could ask the US tech to eval the knee (popliteal space) at the same time - would not be at all surprised to see a big old bakers cyst sitting there...... and bingo you have your cause plan: repeat US LLE - talk to tech before hand and ask them to specifically look at the politeal fossa then maybe repeat some more labs (although I admitt this is very low yield and D-dimer is not really helpful but heck we are shooting at shadows - the problem is what do you do with a postive D-Dimer? get a chest CT ??? whoooaaaaa again....) so I would not repeat any labs..... Refer to someone else - ie vascaular surgery, ortho, hem?? Link to comment Share on other sites More sharing options...
macadamia813 Posted February 12, 2011 Author Share Posted February 12, 2011 Update: Got the abdominal/pelvic U/S back. Only findings are mild R hydronephrosis (no stone/calculus seen) and gallbladder polyps. So we are getting authorization for CT abd/pelvis and urology referral. Also, the patient says she DOES cross her leg...right leg over left. She said since she has been having the swelling, she has made a conscious effort to stop crossing them. However, one would think if she crossed the right side over, the swelling would be on the right. Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 12, 2011 Moderator Share Posted February 12, 2011 Update: Got the abdominal/pelvic U/S back. Only findings are mild R hydronephrosis (no stone/calculus seen) and gallbladder polyps. So we are getting authorization for CT abd/pelvis and urology referral. Also, the patient says she DOES cross her leg...right leg over left. She said since she has been having the swelling, she has made a conscious effort to stop crossing them. However, one would think if she crossed the right side over, the swelling would be on the right. To restate repeat US LLE - talk to tech before hand and ask them to specifically look at the politeal fossa - looking for a bakers cyst... BEFORE CT - why expose to radiation when an US might answer it! also you said the swelling is getting better in the LLE - went from 1" to 1/2" size difference.... I usually use the 2cm difference to justify the US to r/o DVT and you are under this Why are we still looking in belly? it is so far a local issue is it not? no constitutional symptoms, no reason to expouse to 300+ xrays at this time is there - that is her abd adn pelvic organs and if you get with contrast you 'moderatly' increase her life time cancer risk...... correct me if I am wrong but do you have any solid findings to support getting a CT in her case? Link to comment Share on other sites More sharing options...
sbellin Posted February 12, 2011 Share Posted February 12, 2011 Hmm. Right leg edema, mild right hydronephrosis with out a stone. Sounds like potential for pelvic pathology to me. Link to comment Share on other sites More sharing options...
macadamia813 Posted February 12, 2011 Author Share Posted February 12, 2011 To restate repeat US LLE - talk to tech before hand and ask them to specifically look at the politeal fossa - looking for a bakers cyst... BEFORE CT - why expose to radiation when an US might answer it! also you said the swelling is getting better in the LLE - went from 1" to 1/2" size difference.... I usually use the 2cm difference to justify the US to r/o DVT and you are under this Why are we still looking in belly? it is so far a local issue is it not? no constitutional symptoms, no reason to expouse to 300+ xrays at this time is there - that is her abd adn pelvic organs and if you get with contrast you 'moderatly' increase her life time cancer risk...... correct me if I am wrong but do you have any solid findings to support getting a CT in her case? Well, I discussed with my SP and ultimately he is making the decision. Do you really think another US of the LE would do anything? The ultrasound tech has 30 years experience...not saying she is perfect - she could have missed something. The major issue here is we are trying to cover our azzes. Or at least my SP is trying to. He just gave a deposition yesterday. And every time I turn around, there is another legal matter. Not sure how many cases he's had proof of fault or just involvement in care. We could employ a "wait and see" plan, but that could bite us in the butt if it ends up being something and we delayed imaging. It's sad that we have to practice "defensive" medicine :( Link to comment Share on other sites More sharing options...
macadamia813 Posted February 12, 2011 Author Share Posted February 12, 2011 Hmm. Right leg edema, mild right hydronephrosis with out a stone. Sounds like potential for pelvic pathology to me. Apologies...I clarified in an earlier post that it was the Left leg. Sorry for confusion. Link to comment Share on other sites More sharing options...
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