Elephantiasis nostras verrucosa: an atypical presentation following intrapelvic lymphoma

Elephantiasis nostras verrucosa is a progressively debilitating and disfiguring disease commonly presenting with verrucous, cobblestone-like papules, nodules, or plaques with nonpitting edema in the lower extremities. Histopathology is marked by hyperkeratosis and dermal or subcutaneous fibrosis as a result of chronic lymphedema. Risk factors include obesity, recurrent cellulitis, chronic venous insufficiency, congestive heart failure, scleroderma, radiation, trauma, and tumors. We report a 72-year-old man who presented to the dermatology clinic for an 11-year history of edematous legs, occasionally associated with ulcerations. The findings developed within a year of intrapelvic non-Hodgkin lymphoma and progressed gradually over 10 years after lymphoma remission. Physical examination revealed atypical features including compressible cysts and pitting edema extending from the lower legs to the thighs bilaterally. The patient was noncompliant for the recommended compressive devices and the condition progressively worsened over the course of 7 months of follow-up. Early interdisciplinary management using compressive devices and a lymphatic pump are recommended. Underlying causative factors should be assessed with regular follow-up to optimize treatment outcomes.

Treatment of pretibial myxedema with dexamethazone injected subcutaneously by mesotherapy needles

Pretibial myxedema (PTM) is a rare extrathyroidal manifestation of Graves' disease that requires treatment when the clinical picture is markedly evident. In addition to topical treatment with steroid ointments, there have been previous reports of subcutaneous injections of steroids. This procedure may cause nodular degeneration of the skin due to fat atrophy when standard needles are used. In the present study, we have tried a novel modality of treatment of PTM by injecting a solution of dexamethasone in the subcutaneous tissue using needles employed for mesotherapy. These needles are ≤4 mm long and deliver the medication within the dermis or the first layer of the subcutaneous fat. We have treated five patients, four with diffuse and one with elephanthiasic PTM. We utilized multiple injections of a solution of dexamethasone, lidocaine, and saline in the PTM plaque and in the pretibial area, both in the PTM plaque and in the area surrounding the lesions, once a week for three consecutive weeks. Two patients with a more severe form of PTM underwent another two cycles four to six weeks after initial treatment. Patients were studied before and after treatment by clinical assessment and ultrasound of the pretibial skin. The treatment was well-tolerated, with only moderate pain upon injection of the solution. One month after treatment, all patients showed improvement of PTM at clinical assessment and a reduction of the thickness of the lesions at ultrasound of ∼15%, involving mostly the dermis. Moreover, all patients reported amelioration of the leg appearance. The present study, although preliminary, shows that intralesion steroid injection with mesotherapy needles in PTM is effective and well tolerated, and does not cause undesired long-term modifications of the skin. More studies are warranted to standardize such treatment in larger groups of patients.

CT of swollen legs

The use of a single axial slice through the mid calf in the differential diagnosis of a swollen leg is described. This is a very simple quick non-invasive investigation. Venous obstruction results in an increase in the cross sectional area of the muscle compartment. The subcutaneous fat layer is normally homogeneous; in obesity or lipoedema it is increased but remains homogeneous. In lymphoedema fluid collects in the interstitial spaces which become very prominent on CT images. In chronic lymphoedema a honeycomb pattern is seen as a result of increase in the interstitial tissue due to fibrosis. Popliteal cyst extensions result in fluid collections between muscle planes. Haematomas have higher attenuation, and are intramuscular. The findings in 64 patients and 10 controls are presented and the literature is reviewed.

Lymphographic abnormalities in patients with Brugia malayi filariasis and "idiopathic tropical eosinophilia"

Peripheral lymphography was carried out in 17 patients with elephantiasis and microfilaremia (Brugia malayi) and the findings compared to ten patients with "idiopathic tropical eosinophilia." There were extensive changes in peripheral lymphatic and regional nodal architecture in each group suggesting that "occult filariasis" is the cause of idiopathic tropical eosinophilia.

[Typical computed tomographic findings in neurofibromatosis]

Three patients with neurofibromatosis (Recklinghausen's disease) were examined by computer tomography. In this way, the exact extent and localisation of the neurofibromatous tumours could be demonstrated. In one patient, CT provided evidence of malignant change; this was verified histologically. The appearances of neurofibromatosis associated with elephantiasis is described. In each patient, treatment was significantly influenced by computer tomography.

Lymphovenous anastomosis in filarial lymphedema

Correction of established filarial edema requires lymphaticovenous by-pass, to overcome the lymphatic obstruction and debulking to reduce the lymphatic load. Lymphnodovenous shunt at inguinal area has given 90% success in the authors hand, proving the by-pass. However, in an enormously swollen leg the dilated distal lymphatics may not be adequately drained and hence a distal lymphaticovenous anastomosis should theoretically offer further reduction; and thereby make debulking effective. In this article 3 cases are reported in whom lymphovenous anastomosis was done, in 2 at the knee level and in 1 at the ankle, their result and rationale are discussed.