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A Female Teen with Swollen Feet

A Female Teen with Swollen Feet



  • 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.

Comments

Very nice case and well presented /informative. Thanks.

DIEGO @

Thank you for your comment, Mark. You are correct. The chief complaint, however, was "swollen feet."
As always, we record the chief complaint as it is given and expand our diagnosis as we examine our patients and obtain more history.

J. Schneider, author

Jonathan @

Thank you for your comment, Mark. You are correct. The chief complaint, however, was "swollen feet."
As always, we record the chief complaint as it is given and expand our diagnosis as we examine our patients and obtain more history.

J. Schneider, author

Jonathan @

"Swelling in the lower extremities"s not the same as "swollen feet."

Mark @

I really enjoy these presentations. Keep them up!

Joel @

Puede tratarse de un Síndrome de Sudeck o Dolor Regional Complejo con edema, cambio de coloración de la piel con hipersensibilidad en la zona del pie, sensación de calor local. Es desencadenado por traumatismo local, a veces mínimo, por ejemplo un esguince de tobillo. Es un trastorno que afecta el sistema nervioso autónomo, en especial el sistema simpático. Tiene tendencia a la cronicidad y se trata con Sertralina, Gabapentina, analgésicos y en ocasiones se alivia con bloqueo simpático.

RICARDO @

early HSP?

Joseph @

early HSP?

Joseph @

I have to share with you one more story about the House of God...
I read in one chapter that you/I would be paged when we go to the bathroom. My first night on call I was, indeed, paged in the bathroom. That is when I said to myself, Oh Lord - it's all true, it's all true!"
I survived that experience and many others without becoming cynical, however. I love what I do and my theme is a Benjamin Franklin saying that has a lot of truth to it:
"God Heals - The doctor takes the fee."
Jon Schneider, author of this case and others
PGY 43.5

Jonathan @

I love all of your comments and additions. They add to the case tremendously. I read the House of God and I interned and did my residency in the 70's. we did much of the labs lftikhar mentions in the follow-up and that is another excellent comment. I discussed this case with many sub specialists and I remained as the primary physician.
J. Schneider, author
PGY-43.5

Jonathan @

Nephrotic syndrome, renal insufficiency, hypothyroidism, echo to evaluate LV function, cxr, chf, work up would be a good start

Iftikhar @

May Thurner or iliac compression can cause unilateral left leg edema its usually better in AM and worse at the day goes on. Lymphedema praecox also shows up in adolescence. Duplex of iliac veins may show increased velocities. MRV or CTV may show compression.

patricia @

It seems like unilateral (left leg) edema, consider DVT? filariasis??

UDIPI @

"Turfing" is a term coined in a cynical novel about medical interns called "House of God" published in the late '70's that means getting a patient off of your service onto someone else's roster, or referring out...sending the patient on. The book gave rise to a lot of hospital slang we still use today.

Becky @

havbing been an er dr in the county hospital in la and worked at va turfing means you refer the pt to a specialist as the case is beyond your scope of medical care that you can provide; any unilateral edema must consider dvt 1st and then look for underlying thrombophilia such as leiden factor V antiphophopholipid antibody syndrome etc

Robert Franklin @

What's turfing? Don't you mean surfing? As in surfing the web.

ava @

ibuprofen use caused the swelling.

Robin @

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