Elephantiasis Nostras Verrucosa (ENV) Picture and Case Presentation.

Most doctors spend over 90 of their daily practice treating common disease with common presentations or even common diseases with uncommon presentations.  This is our comfort zone. Most doctors rely  heavily on external resources for the evaluation and management of zebras, conditions that aren't routine in the course of a daily medical practice, but are recognized as uncommon presentations of uncommon disease,  So when a patient with  Elephantiasis Nostras Verrucosa (ENV), or at least what I believe to be ENV presents, I am not ashamed to say that a literature search was necessary to help me define the differential diagnosis and guide me through the plan of care from my initial hospitalist work up.  Case presentations on The Happy Hospitalist are always fiction.  However, this one is real.

With  the patient's permission for anonymous online discussion of his situation,  both publically and privately in  a physician only  online network, I am presenting a brief review of the details here, along with his approval for photographic visualization of his disease process, with the hope of finding  experts in our country  treating this condition or finding others afflicted with what I believe to be ENV and who may have knowledge of available resources to  improve his quality of life.  I know a lot of doctors read my site.  All I need is one that can help.  This presentation uses the concept of crowd-sourcing diagnosis.  If two heads are better than one, then certainly a thousand heads are better than two. Crowd-sourcing diagnosis was used recently by a mother who's son's life was saved after a diagnosis of Kawasaki's disease was suggested by astute readers on Facebook.  This is my patient's story
Here is a young male with a greater than 10 year history of progressive unilateral woody, nodular and odorous smelling skin changes of his lower extremities.  He has obstructive sleep apnea from significantly elevated body mass index, defined medically as morbid obesity.    He  has no other relevant medical history, family history, social history, review of systems or physical exam.  His basic laboratory panels (CBC/BMP) offer no concerning abnormalities and carry a normal differential.  He has pain in his legs, which occasionally bleed.  There is no significant pruritis.  He tells me a dermatologist opinion several years ago consisted of "put a sock on it and leaving it alone".
I used Google for a preliminary review of what I believed this presentation to be of ENV.   Google is interesting in that if you know what keywords to use, you can find a wealth of information to help define and refine your differential diagnosis very quickly.  If you don't know what you're searching for, it can be a black hole of worthless and dangerous information. Knowing what you're searching for on Google is different  from the lay person's online symptom checker which leaves too much to the unhelpful imagination.

In some ways, medical school offers doctors the skills to search rapidly and efficiently for defined subsets of uncommon diseases that are not a normal part of their daily practice.   The idea is not necessarily to know everything every time, but to know how to find what you need know efficiently and with accuracy.  That rings true whether you are an internist or an orthopaedic surgeon.  I believe I've made the diagnosis of Elephantiasis Nostras Verrucosa using my medical skill set and the power of observation.  Here is an image. 

Elephantiasis-Nostras-Verrucosa-ENV-Suspected-Mossy-Foot

Why do I think this is ENV?  After reviewing similarly described images and reviewing reputable medical databases with similar case reports of this presentation, I discovered my patient had many similar attributes, both visually and clinically.  Can I be sure?  No.  There is always some uncertainty in medicine.  That's why I'm seeking a little crowd-sourcing help. I know there are no experts who treat this as a part of their routine practice day in and day out in my community because I would be seeing more than one  case in my last eight years as a hospitalist. Nor do I find telling the patient to put a sock on it and leave it alone to be an acceptable long term  management plan.

What are some other common names for ENV?   I have seen reference to ENV being called:
  • Armchair legs
  • Chronic recurrent streptoccocal erysipelas
  • Deckchair legs
  • Elephantiasis nostras
  • Lymphoedematous hyperkeratosis
  • Lymphoedematous papillomatosis
  • Mossy foot
  • Wheelchair legs 
Elaphantiasis Nostras Verrucosa is often described as cobblestone and lichened in appearance with a significant malodorous presentation on the distal extremities.  Frequently, recurrent bacterial infections may set up a continuous inflammatory state that causes chronic and progressive disfiguration of the skin.

A review of the literature suggests the lack of definitive treatment, except for therapies related to lymphedema.  So how about a little help.   If there are any experts out there who are familiar with a visual presentation of this condition or who can suggest alternative diagnostic possibilities that would significantly alter the work up or if there are any patients who suffer from a condition similar to this visual and clinical presentation and you have found significant help through resources or support groups that may not be readily known to most,  I would be grateful to hear your input and I believe my patient would be grateful for your help as well.

Log into your Twitter, Facebook or Google Plus accounts and ask all your medical friends and family if they have an answer for my guy.  He's looking for help and I'm trying to find an answer for a problem that has consumed his young adult life without any definitive plan.  I'm not willing to accept put a sock on it and leave it alone as his long term plan.  Perhaps you will be the one that changes his life forever.

Leave a comment or, if you would prefer to use private correspondence, with your thoughts you can click on my "contact" menu tab at the top of this page and send me a private message.  Alternatively, you can send me an email  at happyhospitalistATgmailDOTcom. 


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