Lymphedema praecox seen as isolated unilateral arm involvement: case report and review of the literature

An adolescent with recurrent ankle swelling

A 14-year-old girl was admitted to our institute with a history of intermittent bilateral ankle swelling, and moderate but progressively worsening pain which has lasted for 2 years.The patient's history was unremarkable. She did not take medications and was not involved in any sports activity. She reported no fever, gastrointestinal symptoms, fatigue, weight loss, travels abroad or previous infections. She reported moderate pain at night, associated with a sense of heaviness, tightness and general discomfort, and with no response to ibuprofen.Physical examination was remarkable only for bilateral ankle non-pitting oedema, more evident on the left leg, with a thickened skinfold at the base of the second toe, and without redness, swelling or skin warming.The patient had been previously examined, and her foot and ankle X-rays, ultrasound (US) and MRI were all negative. Blood tests (white cell count, C reactive protein, erythrocyte sedimentation rate, albumin, antinuclear antibodies, creatinine, transaminase, creatine kinase, lactate dehydrogenase, thyroid function and glucose) and urinalysis were in the normal range. Her ocular assessment and echocardiogram were also normal.

Resource overutilization in the diagnosis of lymphedema praecox

PURPOSE

Primary lymphedema presenting in adolescence is known as lymphedema praecox. Older children presenting with leg swelling are often subjected to a myriad of diagnostic tests. The purpose of this study is to review a large-cohort of patients with lymphedema praecox to determine the fiscal impact of diagnostic testing on these patients.

METHODS

A 13-year review was performed of patients with lymphedema praecox. Information was obtained on demographic parameters, diagnostic studies performed, and clinical outcomes.

RESULTS

Forty-nine patients were identified. The median age was 14 (range: 7-21) years. Participants were predominantly female (n = 40, 81.6%). 19 patients had bilateral disease and 30 had unilateral disease. The diagnosis was made on clinical exam only in 14 patients. 35 patients had imaging which consisted of plain X rays, Doppler ultrasound (DUS), lymphoscintigraphy (LSG) or MRI as the sole imaging study (n = 28) or in combination with others (n = 7). The charges for plain X-rays, DUS, LSG, and MRI with contrast were $335, $1715, $1269, and $6006 respectively.

CONCLUSION

We believe that in the adolescent female with physical findings consistent with lymphedema praecox, diagnostic imaging should be limited to a Doppler ultrasound to rule out a secondary cause of the swelling.

LEVEL OF EVIDENCE

IV TYPE OF EVIDENCE: Case series with no comparison group.

Dysfunction of dermal initial lymphatics of the arm and upper body quadrant causes congenital arm lymphedema

OBJECTIVE

The objective of this study was to explore the pathologic process underlying primary lymphedema.

METHODS

Twenty-seven patients with unilateral congenital arm lymphedema who visited our clinic from January 1, 2014, to May 30, 2019, were enrolled. The patients' clinical signs and the findings of indocyanine green (ICG) lymphography, skin tissue immunohistochemical staining, and whole exome sequencing of tissue and blood were evaluated.

RESULTS

Among the 27 patients, 11 were diagnosed with stage II and 16 were diagnosed with stage III lymphedema. No lymphatic vessels were visualized in the affected arm in 25 of 27 (93%) patients who underwent ICG lymphography; likewise, no lymphatics were found in the territories of axillary lymph node drainage in the trunk, irrespective of any anomalies of the axillary lymph nodes. In only two (7%) patients, an unclear lymphatic trunk gradually appeared in the dorsum of the affected hand. The number of initial lymphatics was increased in the skin specimens of all nine patients in whom lymphatics were not demonstrated by ICG lymphography. Among 14 tested patients, we found compound heterozygote variants in the PIEZO1 gene in only one (7%) patient. Two missense variants, c.4072C>T; p.Arg1358Cys and c.5033C>T; p. Ala1678Val, were identified and found to have been inherited from the father and mother, respectively. No other pathogenic or likely pathogenic variants of currently known lymphedema-related genes were identified in the remaining 13 patients. No genetic difference was found between the lymphedematous and nonedematous healthy skin tissue of the same person.

CONCLUSIONS

Segmental or regional dysfunction of the dermal initial lymphatics causes congenital arm lymphedema and may have implications for clinical treatment.

Isolated primary lymphedema tarda of the upper limb

Primary lymphedema tarda is considered as a congenital disease with late presentation. Primary lymphedema tarda usually affects lower limbs, and primary lymphedema tarda of the upper limbs usually accompanies lower limb lymphedema. In the current case report, we present an 80-year-old male patient with isolated left upper limb swelling that lymphoscintigraphy imaging proved to be lymphedema.