Differentials
Chronic venous insufficiency
SIGNS / SYMPTOMS
Damage to the peripheral venous system can lead to lower extremity oedema, usually without significant foot involvement.
Pain, ulceration, pitting oedema, pigment changes, and a negative Stemmer's sign are present on clinical evaluation.[52] May be considered a risk factor for lymphoedema, and may co-occur with lymphatic compromise.[10][62][63]
INVESTIGATIONS
Duplex ultrasound: reversed flow; valve closure time >0.5 second indicates reflux.
Deep vein thrombosis (DVT)
SIGNS / SYMPTOMS
May be history of prior DVT, prolonged immobility, or hyper-coagulable state.
Usually presents with erythema, warmth, and pain of the affected limb.
INVESTIGATIONS
Duplex ultrasound: presence of a thrombus within the vein.
Lipoedema
SIGNS / SYMPTOMS
Predominantly affects women at times of hormone, weight and shape change including puberty, pregnancy, and menopause; typically bilateral and involves the lower extremities while sparing the feet.
Physical examination usually reveals limb tenderness, presence of a malleolar fat pad, and a negative Stemmer's sign.[18][64]
INVESTIGATIONS
Normal lymphoscintigraphy.
MRI scan of affected extremity shows bilateral subcutaneous fat hypertrophy with sparing of the distal extremity.
Obesity
SIGNS / SYMPTOMS
Class III obesity (BMI 40 or above) results in diffuse, excess adipose tissue and therefore patients may have symmetrically enlarged legs secondary to fat deposition.
INVESTIGATIONS
Normal CT or MRI scan.
Normal lymphoscintigraphy.
Congestive heart failure (CHF)
SIGNS / SYMPTOMS
Characterised by generalised pitting oedema that responds to elevation and diuretics. Because CHF is a systemic illness, extremity oedema is typically bilateral, unlike lymphoedema, which is usually unilateral.
Additional symptoms include fatigue, light-headedness, poor exercise capacity, and shortness of breath.
INVESTIGATIONS
Electrocardiography may show evidence of underlying coronary artery disease, left ventricular hypertrophy, or atrial enlargement. May be conduction abnormalities and abnormal QRS duration.
Chest x-ray may reveal pulmonary vascular congestion (vascular redistribution, Kerley's B lines), cardiomegaly (increased cardiothoracic ratio), or pleural effusion (usually right-sided but often bilateral).
Echocardiogram confirms the diagnosis.
Hypoalbuminaemia
SIGNS / SYMPTOMS
Renal failure and protein-losing enteropathies cause generalised pitting oedema through reduced intravascular osmotic pressure.
Decreased production of protein in hepatic failure similarly leads to generalised pitting oedema.
Oedema is therefore bilateral, unlike many patients with lymphoedema, who have one affected extremity.
INVESTIGATIONS
Low serum protein, low serum albumin, low serum pre-albumin.
Malignancy
SIGNS / SYMPTOMS
Malignancy, including lymphangiosarcoma, angiosarcoma, sarcoma, and lymphomas, should be considered when rapid swelling, weight loss, malaise, or pain occurs.[47]
INVESTIGATIONS
MRI scan and tissue biopsy of the affected site confirm the diagnosis.
Klippel-Trenaunay syndrome
SIGNS / SYMPTOMS
Combined lymphatic, venous, and capillary malformation of an extremity with overgrowth.[3]
INVESTIGATIONS
MRI shows lateral embryonal subcutaneous vein and other venous anomalies. Unlike lymphoedema, malformation involves tissues below muscle fascia.
Hemihypertrophy
SIGNS / SYMPTOMS
Idiopathic enlargement of an extremity is usually a diagnosis of exclusion.[3]
INVESTIGATIONS
Normal lymphoscintigram. MRI does not show any pathology, only enlarged subcutis, muscle, and bone.
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