Progressive Bilateral Leg Swelling

I had the opportunity to work in the rapid assessment GIM clinic yesterday. This is a clinic for patients being discharged from the ED who are too well to stay in hospital, but unwell enough that they would benefit from prompt internal medicine follow up. I saw a gentleman who had progressive bilateral lower limb swelling that had been getting worse for several years. He had no history of heart disease and only medical comorbidities/risk factors were hypertension and dyslipidemia. His limb swelling had begun to affect his ability to walk and was generally a big burden in his life. He had been tried on Lasix with little benefit. On physical exam I found severe bilateral leg swelling with significant skin induration. The physical exam was otherwise benign, notably he did not appear volume overloaded (the JVP was not elevated), and there was no evidence of hepatomegaly or ascites. I proceeded to work through an approach I had developed for bilateral leg edema. I generally think about 3 systems: the heart, liver, and kidneys. I recommended an echocardiogram to assess for any CHF, albumin to check for liver function and as a screen for nephrotic syndrome, and a urinalysis for protein. While my staff agreed with my approach, he brought something up that had not crossed my mind: the patient had a peripheral eosinophilia and had lived in South America. He brought up the possibility of parasitic infection, specific Lymphatic Filariasis. I did some reading about this condition and it seemed like a great hypothesis and we referred the patient to the tropical diseases clinic. I was happy with my initial thought process but this experience taught me that I have a lot left to learn in developing my approach. I will appreciate having an experienced staff fill in the gaps in my learning as I move through training. This experience also reinforced the value of case based learning. Lymphatic Filariasis is not a common condition and even if the patient turns out to have something else, I will remember the entity and be motivated to study it having had to work through it with this case.

- MH