OpenHealth Q&A

Recurrence of Pitting Edema in Lower Legs

A 38-year-old male, weighing 260 pounds and standing at 6 foot 2 inches tall, does not smoke or engage in recreational drugs, with his alcohol consumption being limited to 1-3 drinks weekly. His medication regimen includes: - Methylphenidate 54mg for ADHD - Bupropion 300mg for depression - Clomid 50mg due to testosterone therapy failure for low testosterone levels - Aspirin 81mg, as noted by his cardiologist after managing intermittent atrial fibrillation with CPAP therapy following a mild sleep apnea diagnosis - Vitamin D - Tadalafil 5mg for erectile dysfunction - Tamsulosin 0.4mg, prescribed for nighttime urination issues, which he might discontinue since these have likely improved with CPAP use. In July 2023, my husband's lower legs, especially the lower two-thirds of his shins, showed noticeable swelling accompanied by pitting edema upon pressure. Following a medical examination, the initial diagnosis suggested mild sunburn as the cause. However, this condition has recurred multiple times since then. Based on the classification of pitting edema, it typically registers as Grade 3. Imaging via ultrasound on both legs confirmed the absence of clots and venous insufficiencies. During a recent visit to an urgent care facility (due to a six-week wait for a primary care appointment), the attending physician noted some inflammation of hair follicles and sent a prescription for antibiotics to treat folliculitis, suggesting a possible infection as a contributor to the edema. Moreover, there were instances of purple-red bruising where the swelling was most pronounced, with my husband reporting an "itchy deep inside his leg" sensation. Simultaneously, he exhibited elevated creatinine levels, with all subsequent tests showing increased values except for one, while the rest of the metabolic panel remained within normal limits. His estimated Glomerular Filtration Rate (eGFR) has consistently been normal. In August 2023, he underwent a kidney ultrasound, revealing a rounded lobulated area in the mid-pole of the left kidney measuring 3.3 x 2.9 cm. While this finding is nonspecific, it is strongly indicative of benign renal lobulation. A more definitive renal MRI was advised to exclude any minimal possibility of a neoplasm. Following this recommendation, the MRI conducted in September 2023 yielded the following observations: - LUNG BASES: Normal - LIVER: A 2 cm moderately T2 hyperintense lesion located in the anterior right hepatic dome, showing hypointensity on the portal venous phase but only partially assessed. No hepatic steatosis was noted, with PDFF at 4%, and R2* at 45 s^-1 indicating no iron overload. - BILIARY: Suspected small gallstone and Phrygian cap present. - PANCREAS, SPLEEN, ADRENALS, KIDNEYS, STOMACH, DUODENUM, VASCULATURE, LYMPHATIC SYSTEM, SMALL BOWEL, and LARGE BOWEL: All reported as unremarkable. - BONES: Unremarkable. In the follow-up consultation, we were informed that the liver lesion posed no significant concern and no further interventions were recommended. Given that the swelling persists, I am anxious that his edema may stem from underlying kidney or liver conditions. Elevating his legs and using compression stockings have failed to provide relief. Additionally, he has underwent various other blood tests, and if there are additional examinations that could shed light on his condition, please advise as we may already have them completed.

Answers (1)

3/27/2025, 7:01:17 PM

OpenHealth AI

Persistent pitting edema can be a complex issue, especially in the context of your husband's existing health conditions and recent findings. It is concerning that the edema has recurred despite previous evaluations and interventions. Here are key points and next steps to consider:

Summary of Concerns:

1. Pitting Edema: Recurring and significant swelling in the lower legs.
2. Elevated Creatinine Levels: Persistently higher levels might indicate kidney function concerns, despite a normal eGFR.
3. Liver Lesion: Though assessed as low-risk, any hepatic issue can contribute to fluid retention.

Explanation:

Pitting edema can result from various factors, including venous insufficiency, heart problems, kidney issues, liver problems, and even medications. Since previous ultrasounds have ruled out major clots and structural issues in the veins, and given the normal eGFR yet elevated creatinine, potential causes could include:

• Kidney Function Fluctuations: Even with normal eGFR, intermittent spikes in creatinine can suggest underlying issues.
• Liver Function: Conditions affecting liver function or fluid balance could lead to edema despite a reassuring assessment of the liver lesion.
• Medication Effects: Some medications can cause fluid retention; therefore, reviewing his entire regimen could be beneficial.

Action Steps:

1. Monitor and Document Symptoms:

   • Keep a daily log of leg swelling, any associated pain or color changes, and other symptoms (itchiness, bruising).
   • Track dietary intake (sodium, fluid) and lifestyle factors (exercise, standing time).

2. Consider Additional Testing:

   • Repeat Kidneys and Liver Function Tests: Regular follow-up on creatinine and liver enzymes can help track trends over time.
   • 24-Hour Urine Test: This can help assess kidney function more thoroughly and check for proteinuria, which may indicate kidney issues.
   • Doppler Ultrasound: To evaluate blood flow and rule out any subtle venous or arterial problems in the legs.

3. Lifestyle Modifications:

   • Dietary Adjustments: Reducing sodium intake can help lessen fluid retention.
   • Hydration Management: Adjust fluid intake to balance hydration without overloading the system.
   • Compression Therapy: Since previous attempts at compression stockings were ineffective, consider discussing with a specialist about custom-fitted options.

4. Continued Follow-up:

   • Schedule a consultation with a nephrologist (kidney specialist) to address the concerns regarding kidney function and to evaluate for possible underlying kidney conditions that might not be apparent from initial tests.
   • Consult a hepatologist if there are concerns about any potential liver implications despite current reassurances.

5. Medication Review:

   • Discuss with his healthcare provider about the possibility of medications contributing to fluid retention and whether adjustments are warranted.

Final Note:

Finding the underlying cause of recurrent pitting edema can require patience and persistence. Keeping a detailed record of symptoms and maintaining open communication with healthcare providers will be critical in managing his condition successfully. Remember to advocate for further evaluations if symptoms worsen or new concerning symptoms develop. You and your husband are taking an important step by seeking clarity and solutions, and it's completely understandable to feel anxious during this process.