A 44–year–old female with a past medical history of HIV presented to the emergency room with bilateral leg pain, edema and erythema that was progressively worsening over several weeks. The patient first began to experience this triad of symptoms one year prior to presentation. She had been evaluated during that year with multiple lower extremity duplex studies to rule out deep vein thrombi and treated with multitudes of different antibiotics (multiple hospital admissions) as her diagnosis was presumed to be cellulitis. The patient also had a biopsy done three months prior at another institution of her lower extremity and was told that it was consistent with healing cellulitis. On admission, her vitals were stable and the laboratory values did not demonstrate a leukocytosis. Pertinent physical exam findings included bilateral lower extremities with severe pain out of proportion to touch, erythema, and plus one pitting edema with evidence of stasis dermatitis. She received Vancomycin on admission (diagnosis was cellulitis) and continued to receive the antibiotic for several days following her hospitalization without any improvement in her symptoms. Given the refractory symptomatology, the official pathology report was obtained and both dermatology and infectious disease were consulted. The clinical picture (“refractory cellulitis”, bilateral hyperpigmentation with legs that resembled “inverted champagne bottles”) plus review of the official biopsy results suggested the diagnosis of lipodermatosclerosis rather than cellulitis. The patient was subsequently advised to wear daily compression stockings, perform leg elevation when at rest and started on Pentoxifylline along with discontinuation of antibiotics. The patient’s symptoms improved significantly after the initiation of the new management and discharged home with out patient follow–up.
Lipodermatosclerosis (LDS) is a defined as severe fibrosing inflammation of the subcutaneous tissue that usually occurs in those with significant venous insufficiency. Acute LDS presents as an extremely painful area that is red to violaceous, scaling, tender and warm. Chronic LDS presents as skin tightening with constriction above the ankle giving the leg an “inverted champagne bottle” appearance. This case demonstrates an “acute on chronic” form of LDS, which is an entity that is most often misdiagnosed as cellulitis, phlebitis, inflammatory morphea or erythema nodosum. Treatment of LDS includes compression stockings, leg elevation, using anabolic steroids such as stanazolol, pentoxifyllin and topical capsaicin. It is important to consider LDS in patients with “recurrent cellulitis” as misdiagnosis will lead to more hospitalizations, antibiotic exposure and a latent resolution to a treatable problem.
Lipodermatosclerosis is an uncommon culprit that mimics cellulitis. Early recognition of LDS is pertinent to minimize the morbidity of unnecessary antibiotic therapy, medical imaging and hospitalizations.
Figure 1Erythema and edema with evidence of stasis dermatitis.