Bilateral lower extremity inflammatory lymphedema after an ultramarathon

Total Energy Expenditure and Intake During a 161-km Mountain Ultramarathon

High total energy expenditure (TEE) and rate of water turnover (rH2O) using doubly labeled water (2H218O) have been reported during single-stage and multistage ultraendurance events. At the 161-km distance, less is known about the interaction of TEE, rH2O, and ad libitum energy/fluid intake. This is especially true during the postrace recovery window.

PURPOSE

To measure TEE, rH2O, and ad libitum energy/fluid intake during a 161-km ultramarathon while extending the TEE and rH2O measurement window to a 7-day postrace period.

METHODS

Doubly labeled water was used to monitor TEE and rH2O in 2 male ultrarunners (R1, R2) during a 161-km ultramarathon. Self-reported energy/fluid intake was recorded at crew-accessible aid stations.

RESULTS

Both runners completed the race in 32.8 hours, and TEE over this period was 65.8 MJ (6.5 × basal metabolic rate [BMR], 15,723 kcal, 11,225 kcal·24 h-1) in R1 and 66.5 MJ (7.4 ×BMR, 15,888 kcal, 11,293 kcal·24 h-1) in R2. Race energy intake for both runners approximated 50% of TEE, with reported fluid consumption of 21.8 L and 15.7 L for R1 and R2, respectively. rH2O during the race was 14.6 L in R1 and 15.5 L in R2. During the 7-day postrace period, total TEE and rH2O were 94.7 MJ (1.9 ×BMR, 22,634 kcal, 3245 kcal·d-1) and 41.8 L for R1 and 80.0 MJ (1.8 ×BMR, 19,116 kcal, 2721 kcal·d-1) and 24.0 L for R2, respectively.

CONCLUSION

These data illustrate the expected nutrient and fluid budgets for ultramarathons and describe the challenge of restoring acute negative energy balance following these events.

Inflammatory Lymphedema Masquerading as Bilateral Cellulitis: A Military Dilemma

Bilateral lower extremity inflammatory lymphedema (BLEIL) is a novel condition characterized by confluent erythema and painful edema prominent to the dorsum of the feet and ankles bilaterally following prolonged standing and marching, occurring most often in military recruits. Prolonged standing during the initial week of basic training is thought to cause venous congestion and subsequent inflammatory vasculitis. This condition may be misdiagnosed as bilateral cellulitis, prompting the initiation of unnecessary antibiotic therapy. Increased education and recognition of this new clinical entity would lead to the initiation of appropriate therapy and earlier symptom resolution and, thus, an earlier return to military training. Herein, we describe a small case series of Marine Corps recruit members undergoing their first week of basic training (i.e., "processing week") who developed bilateral lower extremity edema, erythema, and pain localized to the dorsum of the feet and the medial and lateral aspects of the ankles consistent with the diagnosis of BLEIL but were initially diagnosed with bilateral lower extremity cellulitis and received intravenous antimicrobial therapy. With prompt initiation of venous decongestive therapy with leg elevation, both patients had rapid symptom resolution and returned to basic training without any future episodes of symptoms. These cases add to the paucity of data on this clinical entity, illustrate the symptoms and demographics of BLEIL, and describe the importance of recognition and initiation of appropriate therapy.