Dr. Penchilaprasad Kandikattu
Internal Medicine
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
Before six years, my legs had gotten swollen for seemingly no reason, and within a year after that without changing my diet I started to gain an excessive amount of weight. Doctor did not know what it was, so he sent me to every specialist for a bunch of tests then finally a vascular surgeon diagnosed me with lymphedema. My health cover does not include manual lymph drainage and they also denied my request for a lymphedema pump as well.
After four years, my left leg became painfully huge and then I got a wound in the lower back calf area. I consistently got wound care minimum twice a week since then but it is getting a lot worse. It goes all the way around my leg which means that during the night I wake up constantly because of the pain when I turn over. They have tried various compression stockings on me however, they only provide the one that comes to the knee and due to the lymphedema it would have a tourniquet effect and make my leg even bigger and purple at times. Lately, my wound has started smelling bad and the wound care nurse stated that I needed to go to the hospital as I likely have cellulitis. I have gone to the hospital at least three to four times since having the wound and each time they try to treat me in an outpatient setting with IV. However, due to the size of my leg, I cannot walk on it very much so it is extremely hard for me to have transportation to go to get the treatments once a day. They have stopped the iv even though it had not improved and prescribed me oral antibiotics Cephalexin but they did not help either. I went to the hospital last week, as I have been feeling extremely tired with no energy and just an overall sense that my leg is getting really bad as the wound is turning black in some areas. When I got there they took blood tests which I would like to get your opinion on as they did not say anything about the results and ultimately just prescribed me Cephalexin and blamed the wound on my home care nurse and sent me home. I feel like there is something really wrong with me and I am hoping my results will show what is wrong. What should I do next?
Hello,
Welcome to icliniq.com.
Are you a diabetic? Can you send me pictures of your legs, if possible? Is filariasis endemic in your area?
Possible causes are like:
1. Cellulitis of lower limb.
2. Filariasis with lymphangitis.
3. Myxedema with secondary infection.
Also, there is a possibility of peripheral vascular disease or osteomyelitis of the underlying bone with cellulitis.
Primary lymphedema may be treated symptomatically. Malignancy of breast or thyroid or genital organs may also cause lymphedema. Post-surgery, post-radiation, or trauma to lymphatic channels can also present like this. So get done MRI (magnetic resonance imaging) of the leg to rule out osteomyelitis of limb. Use NSAIDs (non-steroidal anti-inflammatory drugs) like Naproxen or Ibuprofen to improve pain. Continue regular dressing and antibiotics. You may also need to take anaerobic coverage like Metronidazole, Tinidazole or Clindamycin to reduce infection. Foot end elevation, compression stockings, electric pumping devices, and manual massage may be helpful. Please review with reports. Please get it done color Doppler of both lower limbs, early morning blood sample for peripheral smear study. Use tablet Diethylcarbamazepine 100 mg twice a day for three days. Please review with reports or consult with your surgeon he will examine and treat you accordingly.
Patient's Query
Thank you doctor,
I have primary lymphedema. I believe it is lymphedema tarda. I am not diabetic no one in my family is either. Elevation no longer makes a difference as some days I am in bed all day and the swelling does not go down at all. I believe you did not let me know what the results of my blood and wound swab test shows. I am not able to get the manual lymph drainage or the compression pump as it is not covered where I live. And I cannot afford for compression pump. As far as the compression, I was told I need above the knee compression so that it does not create the tourniquet effect but no compression at all is covered here unless your lymphedema is secondary from cancer treatment. They have never done an MRI on me though they have done an ultrasound of the leg early on. There are no doctors to really treat that out here so I do not know what to do. Did you want a picture of the wound or the lymphedema? As it is currently wrapped up right now I will show you an older picture of the wound but it is much bigger now but the same type of look.
Hello,
Welcome back to icliniq.com.
I have gone through your investigations already but not showing any significant findings except mild anemia with wound microscopy showing mixed organisms.
Also, it is showing mild staphylococcus growth. But culture and sensitivity report of pus yet to come. Blood culture is not showing any growth. Body also showing CRP (C-reactive protein) elevation means inflammation and serum creatinine is little elevated along with decreased GFR (glomerular filtration rate). Also, it is showing microcytic anemia means deficiency of iron. Along with that serum albumin levels are also low probably due to anemia.
So drink plenty of liquids and water. Use tablet iron once a day for one month. Review with wound culture and sensitivity report and other investigations. It is also better to get it done repeat serum creatinine and blood urea reports. I have seen the wound image it appears like primary lymphedema. It is not filariasis. To increase serum albumin levels, you have to take a little high protein diet.
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Internal Medicine
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