Bilateral Leg Swelling Research Articles

Ectopic Thoracic Kidney and End-Stage Renal Disease in a 38-Year-Old Nigerian

This patient is a 38-year-old housewife who presented with a one-month history of difficulty, in breathing, chest pain and bilateral leg swelling and had a blood pressure of 260/150 mmHg, features of malignant hypertension and hypertensive heart disease. Chest CT scan revealed a chest location of the left kidney. She also had elevated serum urea and creatinine and proteinuria (++). The right kidney was normally located with loss of corticomedullary differentiation. She is on maintenance haemodialysis and is being worked up for possible left nephrectomy.

Retroperitoneal malignant nerve sheath tumor

A 72-year-old white female presented with 3-week history of increasing abdominal pain, bilateral leg swelling, decreasing urine output and shortness of breath. She started to have worsening bilateral leg edema right greater than left. She had Doppler ultrasound of her legs which was negative for deep vein thrombosis. She was prescribed furosemide two times daily with minimal improvement in swelling. A few weeks later, she started to have abdominal pain and shortness of breath. Abdominal pain was new onset, dull, right-sided with no radiation or aggravating relieving factors. She noticed abdominal mass incidentally while taking shower which became more apparent on bending. Her past medical history was significant for hypertension, coronary artery disease with bare-metal stent to the right middle coronary artery 9 years ago and insulin-dependent diabetes mellitus. On arrival, her vitals were 36.4°C, 100/68 mm Hg, 97 per min, 31 per min respiratory rate and body mass index 46 kg/m2. Abdominal examination was notable for a right-sided antero-lateral mass with irregular borders …

Chylous Ascites Controlled with Octreotide

Purpose: Introduction: Chylous ascites is characterized by the accumulation of lymphatic fluid in the peritoneal cavity. The most common causes of chylous ascites in developed countries are abdominal malignancy, lymphatic abnormalities, and cirrhosis; but tuberculosis and filariasis accounts for the majority of cases in developing countries. We report a rare case of chylous ascites caused by alcoholic liver cirrhosis controlled by octreotide. Case Report: A 57-year-old man with a history of chronic alcoholism was seen for gradual worsening of abdominal and bilateral leg swelling. Physical examination revealed abdominal distension, shifting dullness and bilateral lower extremity edema. Paracentesis was performed with the removal of 8 liters of milky fluid. Analysis of the fluid showed serum-ascites albumin gradient (SAAG) of >1.1 and elevated triglyceride level (157 mg/dl). Cytological and microbiological examination was negative for malignancy and tuberculosis, respectively. A computed tomography scan of the chest and abdomen showed cirrhosis and no malignancy was found. Patient was diagnosed with chylous ascites secondary to alcoholic liver cirrhosis. Despite medical management with low salt diet, furosemide and spironolactone; patient required a second paracentesis after 7 days with the removal of 4 liters of milky fluid. Analysis of the fluid again revealed SAAG of >1.1 and elevated triglyceride level (229 mg/dl). Octreotide was started at 100 microgram subcutaneous three times a day. Patient's ascites was controlled and the patient required only one repeat paracentesis over 6 months of follow-up. Discussion: Reported incidence of chylous ascites in cirrhotic patient is 0.5 to 1%. Mechanism of formation of chylous ascites in cirrhosis is poorly understood but can be explained by leakage of lymph due to rupture of dilated serosal lymphatic channels secondary to excessive lymph flow (around 18-20 liters/day). Diagnosis of chylous ascites can be confirmed by high triglyceride level of > 110 mg/dl in the ascitic fluid or elevated ascites-plasma triglyceride ratio of > 2:1. Reduction of Lymph formation and reduction of portal pressure should be the aim of management. Octreotide works by reducing portal pressure by inhibiting glucagon and other intestinal peptides mediated splanchnic vasodilatation. Long term use of octreotide can reduce the formation of chylous ascites and it can even stop formation of ascites by helping repair of ruptured lymphatics.

Collapsing glomerulopathy in sickle cell disease: a case report

IntroductionSickle cell disease has been associated with many renal structural and functional abnormalities. Collapsing glomerulopathy or the collapsing variant of focal segmental glomerulosclerosis is a rare clinicopathologic entity in patients with sickle cell disease that requires timely diagnosis and aggressive management.Case presentationIn this case report we describe a 21-year-old African-American woman with a medical history of significant sickle cell disease and asthma. She was admitted for pain, decreased urine output, bilateral leg swelling and reported weight gain. During her period of hospitalisation she developed acute renal failure requiring dialysis. Further investigation revealed the collapsing variant of focal segmental glomerulosclerosis.ConclusionsAlthough focal segmental glomerulosclerosis is a common feature of sickle cell nephropathy, the collapsing variant of focal segmental glomerulosclerosis or collapsing glomerulopathy has been rarely documented. Even when other risk factors are controlled, collapsing glomerulopathy has a very poor prognosis. This is a rare case of a patient with massive proteinuria presenting as acute renal failure with a very poor response to corticosteroids and a much faster rate of progression to end-stage renal disease.

Sleeping on a Royal Flush

Sleeping on a Royal Flush

Paragonimiasis: An unusual cause of Cor pulmonale; A case report

Paragonimiasis is a parasitic disease caused by the trematode Paragonimus. It follows ingestion of raw or improperly cooked or prickled crab and crayfish. Adult worms can survive for 20 years. A 42-year-old rural dweller was seen at the chest unit with a three month history of cough, chest pain and haemoptysis and a ten week history of bilateral leg swelling. He recalled that his problem dated back to 18 years ago when he first had cough with rusty brown sputum and chest pain. He was treated for pulmonary tuberculosis even though sputum examination did not reveal any AAFB on two occasions. Further enquiries showed that he had enjoyed fishing and hunting for crabs in his adolescent years and ate the young crabs raw. Abnormal findings were mild central cyanosis, pitting leg and scrotal edema jugular venous pulsation was elevated with tender hepatomegaly. Sputum for ova of paragonimiasis which was positive. Packed cell volume was 55%, ESR of 15 mm in the 1st hour. Chest radiograph: patchy opacities, tubular shadowing and prominent pulmonary conus. Echocardiography showed dilated right atrium and ventricle without septal and valvular lesions. Sputum AAFB, A diagnosis of Cor pulmonale due to Paragonimiasis was made and patient treated with Praziquantel. The patient improved markedly and repeated X-ray showed some improvement in the features. Paragonimiasis is an important tropical lung disease. The most frequent symptoms are cough and haemoptysis. The radiological features include cavities, cysts, calcified nodules all of which make differentiation from pulmonary tuberculosis difficult. In endemic areas, patients who complain of cough and haemoptysis should have their sputum examined by an experienced microbiologist for paragonimiasis.

Persistent Hyperleukocytosis in a Young Hispanic Male with Alcoholic Hepatitis

Purpose: Hyperleukocytosis (HL) is rare in alcoholic hepatitis (AH), and may be a marker of poor outcome. We present a case of persistently high leukocytes in a patient with alcoholic hepatitis. Methods: A 27-year-old Hispanic male with past medical history of alcohol abuse presented with acute abdominal distension, bilateral leg swelling and jaundice since last one week. Physical examination revealed scleral icterus, hepatosplenomegaly, marked ascites and pedal edema. Laboratory values revealed HL (32 k/mm3), with left shift and bandemia, AST 113 U/L, ALT 39 U/L, ALP 322 U/L, protein 6.6 g/dL, albumin 2.9 g/dL, total bilirubin 8.5 mg/dL, with a direct bilirubin of 6.3 mg/dL and prothrombin time of 18.7 seconds. Urine drug screen, acetaminophen and ethanol levels were negative. CT Abdomen showed hepatosplenomegaly with fatty liver and ascites, with no evidence of hepatic or portal venous thrombosis. Hospital course showed persistent leukocytosis (29 k-40 k/mm3) despite being afebrile. Extensive workup showed negative imaging studies, pancultures, tagged WBC scan, leukemia screen and bone-marrow biopsy. Liver biopsy revealed alcoholic hepatitis with grade 4 activity and stage 4 fibrosis. Management included salt restriction, diuretics, and pentoxifylline with a slow downward trend in bilirubin and leukocytosis over a period of one month. Results: Pathogenesis of HR in AH includes increase in serum cytokines, interleukin (IL)-18 (proinflammatory), IL-1b (neutrophilia) and TNF-alpha. Conclusion: Role of steroids in AH with HL secondary to inhibition of IL-1b transcription is controversial.

82-Year-Old Man With Bilateral Leg Swelling

An 82-year-old man with a medical history remarkable for chronic heart failure, diabetes mellitus, benign prostatic hyperplasia (BPH), and degenerative joint disease presented to the outpatient clinic with bilateral lower extremity swelling of 1 month's duration. The lower extremity edema was bilateral but slightly worse on the right. The edema worsened during the day but transiently improved when the patient was in the supine position. He had no symptoms of paroxysmal nocturnal dyspnea, angina, or orthopnea. He denied prolonged immobility and had no history of deep venous thrombosis (DVT). He had a history of myocardial infarction 20 years previously with resulting chronic heart failure. Of note, he had no known history of kidney or liver disease and had no remote or recent history of smoking. He denied a history of cancer or recent surgeries.

Compound heterozygous mutations in the PROS1 gene responsible for quantitative and qualitative protein S deficiency

Protein S (PS) is a vitamin K-dependent plasma glycoprotein, which plays an important role in the blood anticoagulant system. The PS gene (PROS1) spans some 80 kb of genomic DNA, composed of 15 exons and 14 introns, and is closely linked to a highly homologous pseudogene (PROS2), whose sequence is 96% identical to that of PROS1 [1]. Congenital PS deficiency caused by PROS1 mutations is associated with an increased risk of thromboembolic disease. In this study, we investigated the molecular basis of a patient with both quantitative and qualitative PS deficiency. A 69-year-old man had a medical examination in our hospital because of progressive bilateral leg pain and swelling. He was diagnosed with deep vein thrombosis (DVT) based on the venographs of the legs. Laboratory tests showed normal values of platelet count, prothrombin time, activated partial thromboplastin time, ATIII activity and protein C activity. Test results for lupus anticoagulant and anti-cardiolipin b2GPI antibody were negative. Total PS antigen, free-PS antigen and PS activity levels were 49.0% (normal range 65‐135%), 26.7% (60‐150%) and 10% (60‐150%), respectively. From these findings, he was diagnosed as having PS deficiency.

Case 1: The case of the irritable nephrotic

A 22-month-old previously healthy boy presented to a tertiary care emergency department with a one-week history of periorbital and bilateral leg swelling. He had no fever, no recent illnesses and no blood in his urine or stool. He was known to have chronic constipation and had a poor diet consisting mainly of cow’s milk. On physical examination, he had no hypertension, was in no apparent distress and displayed normal vital signs. He had marked periorbital edema and pitting edema of his lower limbs. His abdomen was distended and he had mild ascites. The rest of his examination was normal. A urine dipstick showed a high protein level (20 g/L) and a large amount of blood. He had low serum albumin of 18 g/L (normal 32 g/L to 56 g/L), high serum triglycerides of 2.17 g/L (normal 0.31 g/L to 1.41 g/L) and high serum cholesterol of 8.82 mmol/L (normal 3.2 mmol/L to 4.4 mmol/L). His electrolytes and renal function were normal. A complete blood count revealed a low hemoglobin of 79 g/L (normal 110 g/L to 140 g/L) with a low mean corpuscular volume of 53 fL (normal 80 fL to 94 fL). His platelet count was elevated at 934×109/L (normal 150×109/L to 400×109/L). A blood film showed marked hypochromasia and microcytosis. His iron and ferritin levels were both low. He was diagnosed with nephrotic syndrome, as well as iron deficiency anemia (secondary to his poor diet), and was admitted to the hospital. He was initially treated with intravenous methylprednisone because he could not tolerate oral prednisone. He was also started on iron supplementation for his iron deficiency. In addition, the nephrology department recommended starting him on dipyridamole, an antiplatelet agent, because his thrombocytosis and nephrotic syndrome put him at an increased risk for thrombosis. Two days after admission, he was found to be hypertensive and more edematous. He was then treated with two doses of intravenous albumin and furosemide. The next day, his edema had significantly improved. He was switched to oral prednisone and seemed to be doing much better. However, the next day he began vomiting his medications, and was unhappy and irritable. It was thought that he had gastritis from the prednisone and was started on ranitidine. His parents thought he may be constipated and he was also started on lactulose. He had a normal neurological examination. Two days later, he was able to tolerate his medications, and was discharged home despite his irritability. Close outpatient follow-up was arranged. Two days after his discharge, he was seen in the nephrology clinic and was found to be extremely irritable and inconsolable. He had a normal examination, and his edema was markedly improved. He was readmitted to the hospital, and further investigations revealed the etiology of his symptoms.

Endotracheal intubation in the lateral decubitus position: A case report

A 60-year old woman presented with a 2-year history of abdominal distension, early satiety, weight loss, bilateral leg swelling and difficult breathing. Clinical examination had to be conducted in the semi-recumbent position, as the patient was very uncomfortable in the supine position. A diagnosis of advanced intra-abdominal tumour was made, and the patient was scheduled for laparotomy. With the patient in the lateral decubitus position, induction of anaesthesia, endotracheal intubation and laparotomy were done. Laryngoscopy and intubation were relatively easy. A huge right ovarian mass weighing 29kg, was excised at surgery. Anaesthesia and surgery were successful, without adverse incidents. She developed postoperative pulmonary oedema, that resolved after 5 days of treatment. She was discharged on the 20th postoperative day. Sahel Medical Journal Vol. 10 (1) 2007: pp. 34-37

Bilateral Leg Swelling as the Initial and Predominant Presentation of HIV and Associated Pulmonary Arterial Hypertension

Although mortality from HIV has decreased over the last several years as a result of effective antiretroviral therapy, the infection continues to pose significant morbidity. Pulmonary arterial hypertension (PAH), for instance, has been reported to occur in the setting of established HIV infection on only rare occasions and carries a universally poor prognosis. The current case report is unique in describing a previously well patient who presents initially with complaints of debilitating leg swelling and is subsequently diagnosed with HIV and associated PAH.

A case of all-trans retinoic acid-induced myositis in the treatment of acute promyelocytic leukaemia

The use of all-trans retinoic acid (ATRA) is now standard therapy for the treatment of acute promyelocytic leukaemia (APML). There have been increasing reports of ATRA-induced myositis, with its frequent association with retinoic acid syndrome and Sweet's syndrome. We report a case of a young man with APML who developed ATRA-induced myositis characterized by unexplained fevers, bilateral leg swelling and a non-painful purpuric, petechial rash, with prompt resolution of symptoms and signs with high-dose steroids and cessation of ATRA. Rapid recognition of this adverse reaction and prompt institution of steroids is of prime importance given its potentially fatal course.

Liver transplant recipient with bilateral leg swelling

A 50-year-old white male was admitted to the hospital with erythema and swelling of both lower extremities. The patient had a medical history significant for liver transplant five years prior for end-stage liver disease secondary to alcoholic cirrhosis. Following transplant, he developed mitral valve insufficiency with heart failure and pulmonary hypertension. He had been in his usual state of health until approximately a week prior to admission when he noticed that his lower extremities had increased in girth. For several days, he noted that there had also been increased redness and pain over the affected area.

Bonner Venenstudie der Deutschen Gesellschaft für Phlebologie

ZusammenfassungZiel: Die Bonner Venenstudie zur Frage der Häufigkeit und Ausprägung von chronischen Venenkrankheiten in der städtischen und ländlichen deutschen Wohnbevölkerung im Alter von 18-79 Jahren fand zwischen dem 13. 11. 2000 und 15. 3. 2002 statt. Es nahmen insgesamt 3072 Probanden teil, die Response-Proportion lag insgesamt bei 59%. Ergebnisse: Eine Beinschwellung in der Anamnese trat bei jedem 6. Mann (16,2%) und bei nahezu jeder 2. Frau (42,1%) auf. Eine kurz zurückliegende ein- oder beidseitige Beinschwellung in den letzten vier Wochen gab jeder 6. Teilnehmer an. Dies entspricht 14,8% (7,9% der Männer, 20,2% der Frauen). Für Gefäßerkrankungen typische Beinbeschwerden innerhalb der letzten vier Wochen gab insgesamt jeder 2. der Probanden (56,4%) an. Bei der Beurteilung der klinischen Ausprägung gemäß der CEAP-Klassifikation fällt auf, dass lediglich 9,6% der Probanden keinerlei Venenveränderungen aufweisen. Bei 59% bestehen isoliert Teleangiektasien oder retikuläre Venen, bei 14,3% Krampfadern (C2) ohne weitere Zeichen einer chronischen venösen Insuffizienz. Auffällig ist, dass bei 13,4% ein prätibiales Ödem im Rahmen von Venenveränderungen zum Untersuchungszeitpunkt vorlag. Demgegenüber liegt die Zahl der fortgeschrittenen Zeichen der chronischen venösen Insuffizienz bei 3,3%. Die Häufigkeit des floriden oder abgeheilten Ulcus cruris lag bei 0,7%. Schlussfolgerungen: Jeder 6. Mann und jede 5. Frau hat somit chronische Veneninsuffizienz (C3–C6). Die Zahlen zeigen, dass Venenkrankheiten insgesamt nach wie vor eine hohe Prävalenz aufweisen, dass aber die schweren Ausprägungen der chronischen venösen Insuffizienz in den vergangenen 20 Jahren zurückgegangen sind.

Inferior vena caval obstruction from a horseshoe kidney: Report of a case with operative decompression

Horseshoe kidney is a common anomaly with frequent associated anomalies. The confluence of the lower poles of the kidneys lies anterior to the inferior vena cava. The authors were unable to find any reports in the world's literature of a vena caval obstruction caused by the presence of a horseshoe kidney. The authors report such a case presenting as bilateral lower leg swelling.

Controversies in venous ultrasound

Ultrasound is the principal method used for diagnosing deep venous thrombosis in the United States, and its accuracy and limitations are well known. As venous ultrasound examination has matured, several controversial issues, primarily clinical, have arisen concerning the application of this diagnostic method. This article addresses some of the more noteworthy and vexing issues, including, but not limited to (a) the need to examine both legs in patients with unilateral symptoms; (b) the role of venous ultrasound in patients with bilateral leg swelling; (c) the necessary extent of the venous ultrasound examination; (d) the importance of calf vein thrombosis; (e) the significance of negative leg veins in a patient with possible pulmonary embolus; and (f) deep venous thrombosis in patients with occult malignancy. Technical aspects of the venous ultrasound examination, and diagnostic accuracy are not described.

Vena Caval Occlusion after Simon Nitinol Filter Placement: Identification with MR Imaging in Patients with Malignancy

The prevalence of inferior vena caval occlusion associated with the Simon nitinol filter (SNF) was studied at two institutions in the follow-up of filters placed over a 13-month period. Twenty-four consecutive patients with defined indications (contraindication to anticoagulation with pulmonary embolism or deep venous thrombosis [DVT], recurrent pulmonary embolism despite anticoagulation, or extensive DVT [eg, iliofemoral]) underwent placement of a SNF. This patient group includes a high proportion with pelvic or renal malignancy (54%, 13 of 24) or a history of other malignancy. Of these 24, physical examination at follow-up identified 10 symptomatic patients with unilateral or bilateral leg swelling. Of these 10, magnetic resonance imaging, with spin-echo and gradient-echo techniques, demonstrated IVC occlusion in five patients (50%). These data suggest that vena caval occlusion following SNF placement occurs more commonly than previously recognized. Possible contributing factors include reduced venous inflow in patients with prior nephrectomy or pelvic neoplasms, pelvic venous compression by tumor mass, and hypercoagulable states.

Intestinal lymphangiectasia in an adolescent: A case study of edema

We report a patient who presented with bilateral leg swelling, in whom a diagnosis of intestinal lymphangiectasia was made by small bowel biopsy. Failure to consider the differential diagnosis of edema and lymphedema in an adolescent could cause a considerable delay in diagnosis. We present a brief review and approach to the edematous patient.

Post-thrombotic inferior vena caval obstruction. A review of 24 patients.

An analysis of the clinical features of 24 patients with post-thrombotic obstruction of the inferior vena cava demonstrated by phlebography showed that the possible precipitating cause was usually trivial and the onset was often associated with bed rest. The classical physical signs of bilateral leg swelling and dilated superficial abdominal wall collateral veins were often absent. In this series bilateral leg swelling was present in 42% and dilated collateral veins were present in half of the patients.A history of recurrent varicose veins and venous ulcers was common and must be taken as an indication for cavography. The presence or absence of proteinuria is no guide to the level of the caval obstruction. The value of inferior vena cavography in making an accurate diagnosis is emphasized.