Correspondence

Massive Obesity Simulating Lymphedema

N Engl J Med 1993; 328:1496May 20, 1993

Article

To the Editor:

The images of massive obesity simulating lymphedema (Dec. 31 issue)1 are quite impressive. The photograph clearly shows the condition of lipomatosis of the legs, also known as lipedema. When confined to the thighs, the condition is known as “riding-breeches thighs.” When involving the whole leg, it is known as either “billiard-table legs” or “stovepipe legs.” If lymphedema were the cause of this degree of leg swelling, there would also be pitting or spreading edema on the dorsum of either foot in response to pressure, with the chronic skin changes of hyperkeratosis and increased skin markings. None of these signs are evident in the photograph. What were the indications for lymphangiography and magnetic resonance imaging when the correct diagnosis could be made by physical examination?

Victor Loughlin, B.Sc., F.R.C.S.
Lagan Valley Hospital, Lisburn BT28 1JP, Northern Ireland

1 References

1. 1

   Witte MH, Witte CL. Massive obesity simulating lymphedema. N Engl J Med 1992;327:1927-1927
   Full Text | Web of Science

Author/Editor Response

The authors reply:

To the Editor: Dr. Loughlin is correct that the term “lipedema” is often applied to the peculiar condition this patient had. The magnetic resonance images show that the term is a misnomer, because edema is not present. The patient was given the diagnosis of lymphedema several years before we first saw her. She was being vigorously treated with external pneumatic compression at another hospital to no avail. She was scheduled to undergo a debulking operation for intractable lymphedema. Lipedema bears a superficial resemblance to lymphedema, which also occasionally spares the dorsum of the foot. Little is known about the underlying pathophysiology of lipedema with regard to peripheral lymphatic function, the composition of soft tissues, and the presence or absence of true edema1. Because of the ease, accuracy, and safety of intradermal isotope lymphography (also called lymphangioscintigraphy) in demonstrating lymph dynamics2 and the unique capability of magnetic resonance imaging to delineate soft-tissue composition, including fluid entrapment,3 we deemed it appropriate to perform these imaging studies.

We sought to diagnose definitively what we suspected clinically and to direct the approach to the patient's long-term treatment. The images establish that in lipedema the peripheral lymphatic system is normal, soft tissue swelling consists solely of fat, and subcutaneous edema is notably absent.

Marlys H. Witte, M.D.
Charles L. Witte, M.D.
University of Arizona Health Sciences Center, Tucson, AZ 85724

3 References

1. 1

   Lofferer O, Mostbeck A. Lipoedema. In: Foldi M, Casley-Smith JR, eds. Lymphangiology. Stuttgart, Germany: Schattauer, 1983:736.
   

2. 2

   McNeill GC, Witte MH, Witte CL, et al. Whole-body lymphangioscintigraphy: preferred method for initial assessment of the peripheral lymphatic system. Radiology 1989;172:495-502
   Web of Science | Medline

3. 3

   Case TC, Witte CL, Witte MH, Unger EC, Williams WH. Magnetic resonance imaging in human lymphedema: comparison with lymphangioscintigraphy. Magn Reson Imaging 1992;10:549-558
   CrossRef | Web of Science | Medline