A Case of Lower Extremity Lymphedema Secondary to Morbid Obesity

Obesity is a known risk factor for lymphedema, a chronic swelling condition caused by insufficient lymphatic fluid clearance from tissues (see post: Lymphedema is a Common but Little-Known Health Hazard of Obesity).  In our experience it can be particularly difficult for obese patients to be correctly diagnosed with lymphedema.  This is likely in part due to the relative rarity of the disease (and thus knowledge of it), as well as the existence of symptomatically similar conditions in obese people such as venous insufficiency and lipedema.  In this blog post I wanted to describe a case of one such patient, who through her persistent efforts to understand her own condition, eventually found her way to our clinic.  It is important to note that since every patient is different, the course of the disease, patient compliance, and outcome of therapy can vary.

Presentation:

On May 29^th, 2012, a 54 year-old morbidly obese patient (BMI >35 kg/m²) was assessed at our clinic for bilateral swelling in her lower limbs (both legs), including her feet and ankles.  Due to the swelling that had extended into her feet she was unable to wear her regular footwear. Swelling had been present for 5 months prior to our assessment, and she had previously been seen in her home by wound care nurses for ulcerated lesions in the affected areas.  This patient was examined for lymphedema.  Imaging of the vascular system by ultrasound tests ruled out significant venous and arterial system abnormalities, and the patient was otherwise healthy, with no signs of diabetes or history of cardiovascular disease.  A symptomatically similar condition called lipedema was ruled out as a potential cause.  The patient had no prior history of lymphedema, nor any significant lymphedema risk factors outside of an elevated BMI.

Treatment:

The patient was treated with Combined Decongestive Therapy (CDT) twice weekly for 1 month, then once weekly for 3 weeks, before being treated once every two weeks for an additional 3 months.  Education, manual lymphatic drainage, skin care and compression bandaging was performed.  Bandaging took place 2 times per week for the first three weeks of treatment, and was followed by the patient’s own use of Ready Wrap garments for 4 months before graduating to compression stockings (20-30 mmHg, and later, 15-20 mmHg).

Outcome:

The patient’s leg lesions ceased weeping and were completely resolved by week 8.  Fibrotic tissue was markedly reduced at this time, tissue was suppler, and visible swelling was reduced.  The size of the Ready Wrap compression garments decreased from size extra-large to large over the course of their use.  A comparison of photos taken by the patient before treatment was initiated, with photos taken after 20 weeks, show some of the improvements attained.

Patient legs pre-treatment                               Patient legs 20 weeks post-treatment

Summary:

While the underlying cause of lymphedema can vary, the principles of lymphedema therapy can be applied to successfully treat the majority of people with this condition. The largest impediment to therapy remains a misunderstanding and misdiagnosis of the condition, which may be particularly true for the obese population.