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Ultrasonographic features in a patient with long-standing lymphedema

A 41-year-old male patient with a past medical history of fragile X syndrome, intellectual disability, Hodgkin’s lymphoma, hepatitis C, and liver cirrhosis presented with altered mentation, breathlessness, progressive leg pain, erythema, and swelling for a week suggesting cellulitis with sepsis. He was normotensive but had tachycardic 125 beats/minutes, tachypneic 34 breaths/minutes, and a low-grade fever of 100.4°F. Upon examination, he was drowsy. Lower extremities were notable for 3+ pitting edema, especially on the left leg (Figure 1). Lab results were remarkable for WBC of 2.6 × 10/L, platelets of 31,000/μL, procalcitonin of 29 ng/mL, high anion gap metabolic acidosis with bicarbonate of 16 mmol/L and lactate of 8.3 mmol/L. Imaging was performed with ultrasonography (US) and computed tomography (CT), and results were typical for severe lymphedema (Figures 2–3). An isotonic fluid bolus and empirical antibiotics were started for the treatment of cellulitis with probable sepsis associated with chronic lymphedema; his hemodynamic status improved with this treatment.