A 600 lb women presents with pain in the R leg.

The patient was rolled on to her side and this is what was seen.

the arrow represents her hip. What is this condition?

This patient had massive localized lymphedema (MLL) due to morbid obesity.  This was first described by Farshid and Weiss in 1998. The etiology of lymphedema can be primary or secondary with primary being congenital abnormalities in the lymph pathways.  Secondary lymphedema can be related to infectious causes as in filariasis, radiation, thyroid disease,  or lymph node dissection.

The lymph system is rarely discussed but since the capillary network is designed to leak fluid to the extracellular space in order to remove waste products, the lymph system is vitally important in functioning as an alternative circulatory system; returning this fluid to the heart.  At least 8 liters of lymph is collected from the extracellular spaces and carried back to the heart each day.  In the morbidly obese, with a body mass index above 59 this system breaks down and lymph flow slows causing large swellings . Histologically, there is thickened skin, and alternating edema and fibrosis of the dermis with fibrous septae encasing lobules of fat.  The lymph vessels are small and irregular.  In the case of our patient  massive lymphedema swelling was found in the thigh and hip.  Ultimately, if not treated with compression or surgery, there will be fat and skin necrosis. Diuretics can worsen lymphedema because as the patient becomes dehydrated , tissue osmolality increases resulting in the movement of more fluid into the tissue compartment.

As of 2016 obesity rates exceed 35 percent in four states, 30 percent in 25 states and are above 20 percent in all states.  Louisiana has the highest adult obesity rate at 36.2 percent and Colorado has the lowest at 20.2 percent.

 compression for  lymphedema

compression for  lymphedema

 

Our patient was taken to the OR and a diagnosis of fat necrosis was made.  She was treated with antibiotics for cellulitis and sent to a nursing home on a rotating bed.

Farshid G, Weiss SW. Massive localized lymphedema in the morbidly obese; a histologically distinct reactive lesion simulation liposarcoma. Am J SurgPatho 1998;22:1277-1283.

Greene AK, Grant FD. Slavin SA. Loer-extremitiy lymphedema and elevated body-mass index. N Engl J Med 2012;366:2136-2137.

Hart H, Arnold C, PayneJ, Miller M, et al. Massive localized lymphedema: a clinicopathologic study of 46 patients with an enrichment for multiplicity. 2016 Modern Pathology 29:75-82.

Evans, R, Scilley C. Massive localized lymphedema: a case series and literature review. 2011. Can J ‘Plst Surg. 19(3):e30-31