Haroon Shaukat, Children’s National Medical Center

The Case:
11 yo female with PMH of asthma, obesity, and seasonal allergies who presented with 1 day of bilateral lower extremity pain, edema, and vasculitic-appearing rash.

Here’s How You Answered Our Questions:

Discussion:
Yet another case wherein the fellows and attendings come to a consensus. It is always a pleasant surprise to see various answers and opinions on poll responses as they generate a lively discussion. However, that discussion is just as lively when we all are relatively on the same page because our thought processes will inevitably vary.

To image, or not to image, that is the question! Although our case may not be as beautiful as Hamlet’s soliloquy, we can conclude that if you decided to image or not, you were not alone. Many of the members in our discussion felt they could express their reasoning for not obtaining imaging with the family, acknowledging that it may take more time than desired. Others felt it would be easier to say yes acknowledging that the families request was for something relatively non-invasive with very little down side.

Dr. Agrawal reminded us that although many of us are thinking rheumatologic as the source of this patients symptoms, but we should not forget the kidneys. Acute glomerulonephritis can account for many of the symptoms this patient is experiencing. Dr. Mathison reminded us of a mantra we often times have difficulty grasping, which is, we are emergency medicine doctors and often times we will not be able to make the diagnosis. But, deciphering what needs to be done as an inpatient vs. outpatient is of the utmost importance. He also took us on quick tour down memory lane with the pathophysiology of edema. in that there are not that many things that cause systemic edema. Capillary leak (allergic), decreased oncotic (hypoalbuminemia), and increased hydrostatic.

Denouement:
Given that the patient refused to even try to ambulate secondary to pain, a dose of morphine was trialed which improved the pain to 6/10. She was admitted to the Hospitalist service for pain control and arranged for Rheumatology to consult in the AM. As the patient was waiting for an inpatient bed, she was noted to have PVC’s on her telemetry so a formal EKG was obtained, which revealed a couplet. Vasculitis remained high on the differential especially with potentially multi-organ involvement, so the patient was admitted to HKU for telemetry monitoring and an echo was ultimately normal.

Rheumatology advised parvo titers, ASO, anti-DNAseB, LDH, Aldolase, Urine protein/cr, ANCA Panel, ANA, and IgG/M which were ultimately negative.

Dermatology clinically diagnosed this patient with bilateral lower extremity inflammatory lymphedema (BLEIL). Advised RICE therapy.

McCann SE, Dalton SR, Kobayashi TT. Histopathology of bilateral lower extremity inflammatory
lymphedema in military basic trainees: A leukocytoclastic vasculitis of the deep vascular plexus. J
Cutan Pathol. 2017 May;44(5):500-503.

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