Abdominal elephantiasis is a rare entity. Abdominal elephantiasis is an uncommon, but deformative and progressive cutaneous disease caused by chronic lymphedema and recurrent streptococcal or
Lymphedema refers to excessive lymphatic accumulation in the interstitial space and occurs as a result of inadequate drainage. This may result from intraluminal or extraluminal obstruction, and rarely from congenital hypoplasia of the lymph vessels. When the lymphedema persists, there is often fibrous tissue proliferation and the affected area becomes hard and no longer pits on pressure. Elephantiasis is localised lymphedema with superadded bacterial infection leading to chronic skin changes. It is characterized by chronic edematous and thickened skin resulting from the repeated inflammation of the skin and subcutaneous tissue. We present three cases of abdominal elephantiasis in morbidly obese patients.
A 53-year-old, morbidly obese gentleman, with a weight of 725 pounds and BMI of 115, who had been homebound for the past 4 years, presented with worsening abdominal swelling and abdominal wall pain. He noticed progressive increases in the thickness of the abdominal skin over the preceding 2 years. His past medical history was significant for type 2 diabetes mellitus, hypothyroidism, recurrent leg cellulitis, and obstructive sleep apnoea. He had no history of congestive heart failure, cancer, liver, or renal disease. He has had no prior surgery or radiation therapy. His physical exams were significant for diffuse, edematous abdominal wall, and legs. The abdominal skin was thickened, fissured, erythematous, and cobblestone-like in appearance (Figure
Case
A 60-year-old woman with past medical history of multiple sclerosis, depression, and morbid obesity (with a BMI of 94), presented with abdominal pain and purulent discharge from the abdominal wall. The abdomen was markedly distended and sagging. The abdominal wall was edematous, thickened, hyperpigmented, and excoriated at many sites (Figure
Case
A 80-year-old Caucasian female with morbid obesity (BMI of 55) was admitted with worsening shortness of breath and progressive abdominal and leg swelling. Her past medical history was significant for congestive heart failure, hypertension, chronic kidney disease, and morbid obesity. Her outpatient medications included Lasix, aspirin, and statin. Clinical examination was remarkable for thickened skin of the abdominal wall, fissuring, and nonpitting edema of the abdominal wall. Her legs were visiblly swollen and puffy but were nonpitting. Her lungs were clear of auscultation. Her cardiac echo revealed markedly enlarged right atrium and right ventricle systolic pressure with pulmonary artery hypertension (RVSP = 59 mm Hg, TR Max PG = 49 mm Hg). She was started on dobutamine drip, intravenous Nesiritide, and Lasix. Despite the aggressive diuresis, there was only very minimal decrease in the leg swelling.
Abdominal elephantiasis is relatively uncommon in the general population. It is relatively more common in the morbidly obese patients [
Lymphedema may be classified as primary or secondary. Primary lymphedema results from congenital abnormality or dysfunction of the lymphatic vessels. Secondary lymphedema develops as a consequence of destruction or obstruction of the lymphatic channels. This may result from obesity, infection, trauma, surgery, tumor obstruction, radiation therapy, or Kaposi sarcoma [
Morbid obesity can be associated with massive localized lymphedema [
Elephantiasis is an uncommon, but deformative and progressive cutaneous disease caused by chronic lymphedema and recurrent streptococcal or
Abdominal elephantiasis is a rare entity. There are only few reported cases of this abnormality in the medical literature. Thyroid dermopathy, venous stasis dermatitis, and filariasis must be considered in the differential diagnosis. The possibility of filariasis is unlikely in the United States (US) [
Distinguishing pure abdominal wall cellulitis from abdominal wall elephantiasis in obese patients can be challenging. Often the two coexist as abdominal wall elephantiasis predisposes the patient to recurrent cellulitis. A long standing, slowo-l progression course and a history of unsuccessful treatment with antibiotics may suggest underlying lymphedema. The diagnosis can be difficult to confirm. Surgery (exeresis/plasty) may confirm the presence of dilated lymph vessels.
The management of this chronic and deformative disease includes antibiotics to treat cellulitis, topical keratolytics, mechanical massages, oral retinoid, topical benzopyrones [
All the 3 patients refused surgical intervention and preferred conservative management; so they were started on antibiotic treatment in Cases
We have presented three cases of presumed abdominal elephantiasis and reviewed the current literature on the subject. Massive, chronic lymphoedema in obese patients can cause extreme disfigurement and physical disability affecting them on both social and physical levels. Management of the morbidly obese patient with lymphedema requires that the obesity be addressed in a frank and supportive way. Treatment of lymphedema must be linked to the treatment of obesity if long-term success is to be achieved. Physicians should be aware of the great risk and complications of chronic lymphoedema, strive to develop a collaborative approach to care, and be prepared to educate and closely monitor these patients. Management in advanced stages is usually unsuccessful. The initial stages of this condition can be treated more easily with topical therapies. Early diagnosis is important for the treatment and prevention of complication.