Elephantasis Nostras Verrucosa and Psoriasis

Abstract

Sir, A 60-year-old man came to our observation because of hyperkeratotic plaques on the lower limbs, of 8 weeks duration. On physical examination, his legs showed indurated, cobblestone-like, grayish lesions, pink verrucous projections, and nonpitting edema (Figure 1). Kaposi–Stemmer sign was evident. Few psoriatic plaques were present on the trunk and the upper limbs. The patient was affected by morbid obesity (body mass index 41 kg/m). His medical history was relevant for heart failure, venous insufficiency, lymphedema, autoimmune hypothyroidism, and psoriasis. At the time of the first visit, he was receiving furosemide 25 mg/d, enalapril 20 mg/d, thyroxine 100 μg/d, citalopram 20 mg/d, acetyl salicylic acid 100 mg/d, omeprazole 20 mg/d, acitretin 10 mg/d, emollients, and calcipotriol/betamethasone dipropionate ointment. The patient referred a worsening of the peripheral edema and effort dyspnea in the past week. A chest X-ray was taken and revealed pulmonary congestion due to congestive heart failure. He was hospitalized and blood tests were all within normal limits, except for an elevated reactive C protein (45 mg/L). An arteriovenous color Doppler ultrasonography (model MyLab40, Esaote, Genova, Italy) using a 7.5 to 12 MHz linear array transducer confirmed mild to moderate venous insufficiency. Filarial elephantiasis was excluded on the basis of the anamnesis and a diagnosis of elephantiasis nostras verrucosa (ENV) was made. Intravenous furosemide treatment was started, followed after 72 hours by the oral administration of the drug, in association with the increase of oral acitretin to 50 mg/d (0.4 mg/kg/d). Daily cleaning of the legs with chlorhexidine 2% aqueous solution was done to prevent over-infections. The patient initially used compressive bandages and after 2 weeks began to carry graduated support stockings (compression index 23-32 mm Hg). At follow-up visit, 2 months later, the patient had lost 15 kg and the lesions had resolved almost completely (Figure 2). Elephantiasis nostras verrucosa is a rare condition considered an exaggerated form of secondary lymphedema that usually involves lower extremities, deformed by progressive fibrosis of the skin. The term “nostras” refers to elephantiasis involving individuals resident in areas where filariasis is not endemic. ENV is clinically characterized by hard, thick, warty, or papillomatous projections and cobblestone-like lesions, with nonpitting edema. ENV mainly affects the lower limbs, even though it has been reported in external genitals, abdomen, buttocks, upper limbs, and face. The diagnosis of ENV is based on clinical history and physical examination. Skin biopsy, computed tomography, magnetic resonance imaging, lymphangiography, and 486156 IJLXXX10.1177/1534734613486156The International Journal of Lower Extremity WoundsSavoia et al research-article2013