A 61-year-old woman with chronic leg lymphedema managed with complete decongestive therapy

A 61-year-old woman presented to her family physician’s office with long-standing bilateral leg swelling. She voiced that her legs had become “heavy” and that the skin was “thick” and “burning.” She had started using a cane for gait instability.

An insidious onset of swelling in her left lower leg had started more than 25 years earlier without any obvious cause. A diuretic was initially prescribed; however, the swelling progressed. The patient was subsequently prescribed various diuretic dosing regimens, with minimal improvement. The diuretic was eventually stopped 3 years before the current presentation.

Over the years, the patient’s right lower leg had also begun to swell. She had undergone venous Doppler ultrasonography of the peripheral extremities 16 years earlier to rule out venous pathologies and was evaluated for liver disease and congestive heart failure. The results of the investigations were negative.

The patient’s medical history included overactive bladder and osteoarthritis. She had no history of coronary artery disease, venous thrombosis or liver disease. There was no family history of lymphedema. She was taking solifenacin 5 mg/d for overactive bladder and a calcium supplement.

On physical examination, the patient had bilateral nonpitting leg edema (Figure 1). The left lower leg was larger than the right, and the ankle anatomy was obscured on visual inspection. The skin of both lower legs was thick and rigid on palpation, with deep skin creases and areas of hyperkeratosis, and there was mycosis of the left first toenail. Stemmer sign (Box 1) was positive. There were no signs of venous thrombosis. Bilateral leg ultrasonography showed normal and competent peripheral veins.