LB876 Acute inflammatory edema: A challenging diagnosis in a critically ill patient

Abstract

A 55-year-old man with a prior history of fibrotic lung disease was admitted to the hospital for bilateral lung transplantation. His post-operational course was complicated by severe volume overload requiring initiation of continuous veno-venous hemodialysis (CVVHD). During this hospitalization, he had developed erythematous plaques over his bilateral thighs. Examination revealed erythematous and edematous plaques with a peau d’orange appearance extending over his bilateral thighs and abdominal pannus. Importantly, the inguinal and infra-abdominal folds were spared. The clinical differential diagnosis included acute inflammatory edema (AIE), early lipodermatosclerosis (LDS), and stasis change. Punch biopsy of a thigh lesion revealed prominent dermal edema, a sparse perivascular and interstitial lymphohistiocytic infiltrate, ectactic vessels, and fibrosis: findings consistent with a diagnosis of AIE. Improvement of the patient’s volume status, increased mobility, and frequent position changes were recommended. AIE is a variant of pseudocellulitis characterized by erythematous and edematous plaques primarily found on the thighs and abdomen that spare areas of increased pressure, such as the inguinal folds. AIE is an acute lymphedema that predominantly affects critically ill patients with hypoalbuminemia, increased body mass index, renal impairment, and evidence of fluid overload. LDS and stasis dermatitis can also present on the thighs and pannus; however, these conditions also commonly manifest on the distal lower extremities and do not spare skin folds. Additionally, LDS and stasis are typically chronic rather than acute. LDS is a lobular panniculitis with fat necrosis, lipomembranous change, and septal fibrosis. In stasis, there are an increased number of thickened capillaries, red blood cell extravasation, and siderophages.