All Is Not Swell

ANSWER

The correct answer is elephantiasis nostras verrucosa (ENV; choice “d”). Cellulitis (choice “a”), venous insufficiency (choice “b”), and lymphedema (choice “c”) are all factors in the broader diagnosis of ENV.

DISCUSSION

ENV is an unusual condition that represents hypertrophic fibrosis secondary to repeated episodes of lymphangitis. This begins with venous insufficiency, which is made worse by increasing obesity (which impedes venous return) and repeated bouts of cellulitis. With ENV, fibroblasts are increased due to extravasation of high-molecular-weight protein (lymphorrhea), which leads to a buildup of keratinocytes, ultimately expressing as extreme hyperkeratosis.

In this patient’s case, his sedentary lifestyle and constant seated position contribute to the problem. Many of his past treatments were reasonable, but—as in many ENV cases—his condition is beyond the point of treatment.

Typically, in-home treatment includes compression and elevation of the legs. Topical application of urea creams is often used to soften the rough skin, but in this patient’s case, the cream burned so badly that it was of no use. Alas, the very things he needs to do are those he cannot: walk, burn calories, and avoid long periods of inactivity.