Reason for oedema and itchy fluid-filled lumps?
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In XXXXXXX 2013, a friend noticed that my left lower leg was oedematous and red and my feet and toes bilaterally were a dusky blue. Pulses were strong and equal both sides, capillary return was normal and the same bilaterally. I had a small, slow to heal lesion on my left lateral lower leg, whose cause I was unsure of. The oedema in the left lower leg deeply pitted. There was no significant oedema on the right but there was a little. Relevant history is good genera health until 2007 when I developed Post Traumatic Stress Disorder as a result of being a victim of crime. In fact, I experienced multiple traumatic incidents at the hands of an extortion gang that targeted me from September 2005 until 2010. A number of attacks mounted by the gang were life threatening but Police were disbelieving and refused to properly investigate or to protect us. Stress levels reached an extreme when my wife and I were finally set up to appear guilty of crimes we did not commit and had to defend ourselves against the full weight of the Justice System. My Post Traumatic Stress Disorder was formally diagnosed in February 2007 and I have been treated ever since with Escitalopram 40mg/day and Propranolol 160mg/day. This regimen has greatly relieved the worst of my anxiety, although I remain symptomatic. As a result of security concerns and Escitalopram related carbohydrate craving, my predominantly sedentary lifestyle and increased appetite led to a 30kg weight gain from 75kg in 2005 to 105kg a month ago. In XXXXXXX 2012, my GP detected an abnormal Fasting Glucose of 9.0 and a raised Cholesterol of 7.5. I immediately had myself referred to the Diabetic Institute at the Baker Institute at the XXXXXXX Hospital in Melbourne. Normalisation of my lab results occurred within 3months of commencing diet etc. Results a week ago showed Random Glucose 6.9, Cholesterol 4.5 and HbA1c was 7.0. No anti-diabetic medication has been prescribed. My Vitamin D level was very low and I now take 2tabs/day of supplemental VIT D. Back to my legs. In XXXXXXX 2013, I attended the ED to exclude a left sided DVT and to seek diagnosis. No DVT OR venous Insufficiency was detected. It was garden and house spider season and the leg lesion was thought to be a spider bite and was bandaged up. I had advanced venous sonography shortly after and no venous insufficiency or valvular incompetence was detected. I had a long history of being a saltaholic, so 2weeks ago I completely ceased using added salt, thinking of fluid retention as possibly present. Two days later terribly itchy lesions began to form. My lower legs and feet have been driving me nuts ever since. Lumps continue to emerge at a rate of up to 20/day. They develop rapidly into fluid filled vesicles and become intensely itchy. The itch remains until the top of the vesicle is removed and the fluid released. The fluid is serous in nature. There is no pus.The itch then slowly settles. The lesions are excoriated, bleeding and ugly. There is no let-up because new lesions are constantly forming. I wear socks to bed, over diprasone. I tried 4 days of Prednisolone 25,25,12.5,12.5 - no real change. Scared to take more due to risk of diabetes. Is identical to sandfly bites BUT they all are at same stage - these keep coming! Endocrinologist had no idea other than "inflammatory". Dermatologists will have long wait for appt. I may have to speak to XXXXXXX Goodman or XXXXXXX Lanzer and beg to be seen asap. Last two nights had to take Valium to get some relief or I would not have slept at all. Covered legs in Betadine at 4am. Fearful of cellulitis occurring in fragile, damaged skin. Risk of septicaemia on my mind if cellulitis takes hold. Trying 360mg Telfast/day - so far 3days but no relief. Oedema still persists with left > right. Still on zero salt. Tried Natrilix x3 days - no impact on oedema suggests problem is local not systemic. Feels a lot like Dyshydrotic eczema did the one time I had some on my little finger many years ago. We have 4 cats. I have gotten used to them. I suffered Hay fever from about 7yrs of age. I shall send several pics as soon as I annotate them. Out of ideas - will pursue dermatology opinion. What is going on? Kind Regards, Dr XXXXXXX Gelb (psychiatrist) DOB: 29/01/1958 .........almost 56yrs old Private Practice - Part Time - Income Protection for Chronic Post Traumatic Stress Disorder.
Posted Tue, 4 Mar 2014 in General Health
Answered by Dr. Prasad 8 hours later
Brief Answer: I would appreciate more pictures... Detailed Answer: Hi, Oedema that pitts with pressure is from fluid retention. After going through the details submitted twice, I opine that you more likely have edema secondary to fluid retention. Over a period of time, skin gets inflammed secondary to retained fluid resulting in oozing blisters/vesicles with itching - a condition known as stasis dermatitis. If your doctors are convinced there is no significant abnormality found on Doppler ultrasound scans, I would order for a renal, cardiac as well as liver function studies. Complete hemogram, ESR, liver and renal panel tests as well as an echocardiogram are going to be the essential tests. Since you planned to visit a dermatologist; go ahead with the appointment. Discuss about stasis dermatitis during the visit and let me know the update. I have had couple of patients with stasis dermatitis. If you can send me pictures of the whole limb, the areas affected and normal skin area, I would be able to confirm my opinion. Looking forward to continue this discussion. Regards
Follow-up: Reason for oedema and itchy fluid-filled lumps? 32 hours later
Dear Dr XXXXXXX I hope that you received the extra pics. I have already had normal FBA, U&E, ESR ECG was also normal. My medications have not changed in years. We have 4 cats and although i am prone to allergic rhinitis, i've adapted to the cats. I was definitely eating too many carrots as a substitute for snacks but on the advice of my endocrinologist, i eliminated the carrots a few weeks ago. If venous stasis is the problem, how could 4D Doppler U/S be normal? Could some form of contact dermatitis cause this? Could I have been exposed without my awareness, to an allergen or toxin? thank you, Kind Regards, XXXXXXX
Answered by Dr. Prasad 13 hours later
Brief Answer: Better pictures if possible... Detailed Answer: Dear XXXXXXX The pictures you sent reveal affected toe. Since you mentioned the left leg is edematous, I figured complete foot or part of the leg; the pictures don't reveal other areas of the body. I would need to look the entire affected area and not part of the lesion to be able to comment on it. Anyway, as discussed earlier, stasis "dermatitis" would be my first possibility. Stasis occur either due to venous incompetency, venous blocks or due to reduced venous return. Doppler scan is not sufficient to comment if you have reduced venous return, your doctor need to perform other tests (as discussed earlier) to exclude reduced venous return. If the dermatologist appointment is around the corner, you can plan these test after the consultation. In the meanwhile I recommend that you keep your feet elevated at most times. Avoid prolonged standing and walking around. If there are no plenty of weeping wounds, you can also use compression stockings or crepe bandage to prevent worsening. Good luck with the appointment... Keep me updated. Regards
Follow-up: Reason for oedema and itchy fluid-filled lumps? 7 days later
Thank you Dr XXXXXXX I managed to see a Dermatologist who biopsied the lesions. I hope to know more soon. I will let you know what is found. Kind Regards, XXXXXXX
Answered by Dr. Prasad 16 hours later
Follow-up: Reason for oedema and itchy fluid-filled lumps? 1 hour later
Answered by Dr. Prasad 34 minutes later
Brief Answer: Biopsy should make it clear... Detailed Answer: I am not sure if an eczematous reaction can present with significant odema; but as the dermatologist had a close look on those lesions I wouldn't disagree with that. Autoimmune disorder also present with inflammatory changes. Biopsy should make diagnosis easier. I am happy its done. So lets wait. Regards