Persistent foot and leg swelling in a 17-year-old female.

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Date: Oct. 2021
From: Contemporary Pediatrics(Vol. 38, Issue 10)
Publisher: Intellisphere, LLC
Document Type: Article
Length: 1,699 words
Lexile Measure: 1940L

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THE CASE

A 17-year-old girl presents with a 2-year history of unilateral swelling of the left lower extremity. The patient reports a poorly healed ankle sprain of the affected extremity 3 years prior that slowly resolved but left persistent swelling. She states that the swelling fluctuates, reaching as high as the midcalf, but has persistent baseline enlargement compared with the opposite foot.

History

Medical history includes hypothyroidism, successfully managed with levothyroxine, which was discontinued 3 years earlier as thyroid function tests normalized. She reached thelarche at age 11 years and menarche at age 13 years. Developmental and family history are unremarkable and noncontributory.

Physical exam

Upon examination, vital signs and growth parameters are normal. The left foot is notable for nonpitting edema to the level of the malleoli (Figure 1); it is nontender and without discoloration. Kaposi-Stemmer sign (inability to pinch the skin at the base of the second toe) is positive (Figure 2). The remainder of her examination is normal with no evidence of thyromegaly, lymphadenopathy, hepatosplenomegaly, or swelling of the other extremities.

Laboratory testing and imaging

Thyroid function tests, complete blood cell count, and chemistry panel obtained at presentation are normal. Abdominal and pelvic ultrasounds do not reveal any evidence of an obstructing mass or other abnormalities. Magnetic resonance imaging without contrast is negative other than an incidental finding of tarsal coalition, mostly fibrous, between the calcaneus and talus.

Differential diagnosis

The differential diagnosis for chronic unilateral lower extremity swelling in an adolescent includes lymphatic and venous etiologies of edema, as well as lipedema (Table). Lymphatic etiologies include primary and hereditary processes (often distinguished based on age of presentation), secondary causes, and associated genetic syndromes. Venous etiologies include congenital venous malformations, venous insufficiency, and external venous compression from tumor, trauma, or other mechanical obstruction. (1) Edema from congenital venous malformation would likely present earlier in life, and venous insufficiency would be uncommon in an otherwise healthy adolescent. Furthermore, venous edema is usually pitting and often accompanied by hyperpigmentation of the extremity because of hemosiderin deposition. (2) Although lipedema is caused by fat maldistribution rather than edema, it can present similarly to venous or lymphatic edema. It is often exquisitely tender and nonpitting and spares the foot. (3) Systemic causes of edema such as congestive heart failure, nephrotic syndrome, protein-losing enteropathies, and cirrhosis are more likely to cause bilateral, pitting edema. (2) Myxedema can also be noted in advanced stages of hypothyroidism but is typically accompanied by other findings (eg, bradycardia, weight gain). (2) Certain medications--notably, calcium channel blockers, corticosteroids, and chronic use...

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Gale Document Number: GALE|A679076284