Case 181: Therapy Restores Leg in Obese Lady with Recurrent Stasis Disease and Cellulitis.

At age 62, this women presented to the Emergency Room of the Bryn Mawr Hospital on January 24, 1993 with a chief complaint of a pink swollen lower left leg. Obesity, cigarette smoking and a history of a mastectomy for breast cancer were important items in her past history. Her temperature was 99.6 degrees F and her white count was slightly elevated to 10.4 (with 5 bands). Blood cultures were drawn and then 1.0 gram of cefazolin was administered intravenously. The emergency room physician recommended admission to the hospital but she refused insisting that she had to care for her sick husband at home. The physician then prescribed cephalexin 500 mg to be taken every six hours, rest and elevation of her leg, and the application of a heating pad. He discharged her with a diagnosis of cellulitis of her calf and referred her to our boot clinic where she arrived on January 25th.

The circumference of her left ankle was one inch larger than that of the right ankle. Venous outflow studies were normal. Venous Doppler studies were normal at the groin and at the knee but sounds in the posterior tibial vein were hard to find and, while easily augmented by squeezing the foot, were not spontaneous. Her transcutaneous oxygen level (TcPO2) was 80 mm Hg on her chest and 9 mm Hg over her lower leg. Conversely, the TcPCO2 level was 36 mm Hg on the chest and 42 mm Hg on the leg. The findings were compatible with her clinical diagnosis of cellulitis and possibly superficial phlebitis of the lower leg. She was advised to continue with her rest, elevation, and local heat application. In addition as a fungus infection of her foot was found, she was also provided with some Lotrimen cream. The inflammation abated but swelling of her leg persisted in spite of the usage of supporting elastic hose. On February 10th, the circumference of her left ankle exceeded that of her right by 3cm and the circumference of her left foot exceeded that of the right by 1 cm. She began on outpatient boot therapy. After a few treatments the difference in the ankle circumferences was but 25 mm. She was discharged with advice to lose weight, to use her supporting hose, to take aspirin and to return immediately if reddening or swelling should recur.

She did not lose weight. Her leg did well, nonetheless, until March 9th, 1995 when she awoke with a headache and a swollen left leg. She reported to her family physician who thought she had "a virus" and superficial phlebitis". He prescribed ibuprofen, leg elevation and heating pad. Her leg became crimson. She again reported to the Emergency Room and this time was admitted to the Boot Service.

As she had not felt that the heating pad was helping her, she had turned up the heat and wondered if she had burned herself. A red streak up the inner calf and thigh (not shown) suggested a spreading cellulitis. This picture was taken on her 4th hospital day when her insurance company was questioning the need for her hospitalization.

Her white count was elevated to 11.5 (43 polys, 44 bands, 9 lymphs, 1 lymphocyte variant, and 1 monocyte) on admission. Blood cultures revealed no growth. A persistent mild elevation on her serum calcium and parathyroid hormone pointed to mild hyperparathyroidism. She was started on heparin on admission and eventually switched to coumadin on which she was discharged. The first few days, she was treated with bedrest, leg elevation and intravenous cefazolin. Persistent leg swelling and her previous history of phlebitis raised the likelihood of the post-phlebitis syndrome. She was started on Long-Boot therapy effectively reducing her swelling in a few days.

The crimson color was slowly replaced by a bronze color. Superficial layers of skin peeled off. The inner lower leg appeared somewhat devitalized. March 27th, the day of this picture, was the last day her insurance approved her hospitalization.

She was discharged on oral cephalexin and coumadin and advised to elevate her leg at home, wear an ace bandage when out of bed and to get out patient Long-Boot therapy.

The leg color continued to improve. Here on April 26th, however, the leg continued to be firm leading us to recommend continued boot therapy.

She returned three years later at 229 pounds. She had had a respiratory infection and stopped her coumadin. Stasis pigment was obvious in both calves.

Comments: Booting on swollen phlebitic legs has the potential of causing a pulmonary embolus. We delay therapy until we are sure the deep veins are likely free of thrombi and commonly until the patient is well anticoagulated. The swelling in this lady was not reduced by bed rest and elevation of the leg. Pumping clearly was beneficial. Edematous legs are also hard to clear of infection; bacteria swim while leukocytes crawl. The addition of booting in the hospital appeared to help us control her infection. At the time of discharge in 1995, the texture of her skin was close to normal... a pretty good result for a leg which had had a severe inflammation process.