A 46-year-old woman comes to the clinic due to left lower extremity swelling for the past 2 years. She has had several episodes of cellulitis involving the left leg. During the most recent episode 6 months ago, she underwent treatment with intravenous antibiotics that was complicated by a catheter-related axillary vein thrombosis requiring 3 months of anticoagulation therapy. Her medical history is also significant for diet-controlled type 2 diabetes mellitus. BMI is 34 kg/m². Physical examination shows firm edema of the left lower extremity. There is no erythema or warmth. The examiner cannot lift the skin from the dorsum of the toes on the left foot but is able to do so with the toes on the right foot. Which of the following is the most likely cause of this patient's symptoms?

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11ec25c8_d0db_1c26_bc81_5f6844eea264_MD0003_00 This patient most likely has chronic lymphedema of the left leg. Lymphedema most commonly results from an acquired disruption of the lymphatic system that leads to accumulation of lymphatic fluid in the interstitium. Common causes include malignancy and its treatment (eg, radiation, lymph node dissection), chronic inflammation (eg, recurrent cellulitis, connective tissue disease), and severe chronic venous insufficiency. Obesity is often a strong contributing factor. Lymphedema Chronic lymphedema typically presents with pain, swelling, and heaviness in one or more extremities. Patients with early disease usually demonstrate soft skin with pitting edema. However, progressive deposition of subcutaneous collagen and adipose tissue occurs, leading to later development of firm, thickened skin and nonpitting edema. In advanced cases, the skin may develop a warty appearance. Inability to lift the skin on the dorsum of the second toe (positive Stemmer sign) is highly specific for lymphedema. The diagnosis is usually based on clinical presentation, but imaging (eg, duplex ultrasound) may be useful in some cases. Treatment is challenging and may involve weight loss, limb elevation, compression bandages, and physiotherapy (eg, lymphatic drainage by massage). (Choices A and C) Severe albuminuria (eg, diabetic nephropathy) can lead to peripheral edema due to low oncotic pressure of the blood, and increased central venous pressure (eg, heart failure) can lead to lower extremity edema due to elevated hydrostatic pressure in the deep veins of the legs. Lymphedema, evidenced by thick skin and a positive Stemmer sign, is not typical in either setting. (Choice D) Systemic sclerosis often leads to peripheral edema due to inflammatory disruption of blood vessel walls; lymphedema due to inflammatory disruption of lymphatics can occur but is less common. If systemic sclerosis were present in this patient, other suggestive features (eg, sclerodactyly, Raynaud phenomenon) would be expected. (Choice E) Venous valve incompetence is the major cause of lower extremity edema due to chronic venous insufficiency. When severe, lymphedema may occur due to lymphatic obstruction. However, this patient's unilateral symptoms and history of recurrent cellulitis make venous valve incompetence an unlikely underlying cause. Educational objective: Chronic lymphedema is most commonly caused by an acquired disruption of the lymphatic system (eg, chronic inflammation, malignancy) and typically presents with pain and swelling in one or more extremities. Patients usually have pitting edema that later progresses to nonpitting edema accompanied by firm, thickened skin. References: Prevalence and characteristics of lymphoedema at a wound-care clinic. (http://www.ncbi.nlm.nih.gov/pubmed/27068342)

A 46-Year-Old Woman Comes to the Clinic Due to Left