Lymphedema Research

Lymphedema Family Study

WHERE: University of Pittsburgh

PURPOSE: To determine how lymphedema is inherited in families

GOAL: To identify genes responsible for primary LE

TYPE: Linkage study

HOW: Comparison of genetic material between family members with/without LE

RESULTS to DATE: Two genes identified that cause primary LE – VEGFR3 and FOXC2

VEGFR3 Vascular endothelial growth factor receptor 3 This was the first LE gene identified. It is located on chromosome 5 and is involved in the formation of lymphatic vessels during prenatal development. There are several published articles about this gene.

http:///www.pitt.edu/~genetics/lymph/update.htm

FOXC2 Second LE gene identified. This gene causes lymphedema-distichiasis syndrome (LD). People with LD have pubertal or adult onset LE, as well as distichiasis. Distichiasis is the presence of extra eyelashes. These eyelashes may present as long and think, or may become ingrown, when they are often removed. Infrequently, these people may be born with a heart defect, cleft palate or ptosis (droopy eyelids).

Not all hereditary LE is caused by these 2 genes, so we know there must be at least one more gene responsible for this type of LE. Study is ongoing and results will be published as possible.

Lymphedema Genetics

Complete information on both the VEGFC gene and the FOXC2 gene

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Lymphatic Research Foundation

The Lymphatic Research Foundation is a 501(c)(3) not-for profit organization whose mission is to advance research of the lymphatic system and to find the cause of and cure for lymphatic diseases, lymphedema, and related disorders.
LRF's immediate goals are to increase public and private funding for lymphatic research and increase public awareness.

* editor's note: I very highly recommend the LRF and hope my readers will support this tremendous organization.

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Additional Information on Lymphedema Research:

Lymphedema Research Centers

Measure of a Heart

No one can Measure a "Heart"by a yardstick or a scale; nor can it be touched like a tender petal; or inhaled like the fragrance of a rose.

No one can Measure a "Heart"by a dazzling revelation of wealth; nor by shiny golden trophies on the mantle; or bronze statues in the city square.

No one can Measure a "Heart"by the glittering lights on a Christmas tree; nor by the number of gifts underneath; or the extravagance they display.

A "Heart" cannot be Measured, but...it is demonstrated in so many ways:

as hands that wash the feet of others in a humble spirit; as the hands that reach out to the lost in a kind spirit;

as hands that lift the burdens of the afflicted in a courageous spirit;

as hands that bandage the wounds of the injured in a merciful spirit;

as hands that embrace the lonely in a compassionate spirit;

as hands that visit the fatherless and the elderlyin a tender spirit;

as hands that feed the hungry and the feeble in a loving spirit;

as the hands that wipe the tears of sorrowin a sharing spirit;

as the hands that soothe the distress of the mourning in a sympathetic spirit;

as hands that pray for supplication in a selfless sprit;

as hands that touch the "heartbeat" of others...

No one can measure a "Heart", for it is never still, but like the flowing river, is known only by its path.

Small Things with Great Love

As the Lymphedema Stakeholders bounded the steps of Raymond buildingfor the press conference and then to storm senator's offices, Ithought about all the therapists and patients around the country affected by recent litigation. For those who may not have heard, a recent 2005 Medicare ruling limited therapist reimbursement for lymphedema to PTs, PTAs, OTs, OTAs, and Speech and Language Pathologists. The ruling caught most of the affected therapists and clinics completely unaware. Clinics failed, patients suffered. Mostof us were taken agast, while some did nothing. I thought about the small lymphedema community, and wondered what type of political rifts had formed, were forming, would be formed. I briefly wondered why and how I got involved. But then I rememberedone of Mother Theresa's quotes which states that none of us can do great things, but we can all do small things with great love.

The statement really fits the lymphedema community. Many people with different educational backgrounds, who became therapists by falling into it or being drawn into it by seeing an unfit need. Perhaps this is what drove the Lymphedema Stakeholder's foreward with such passion on to capital hill. It was the remembrance of decades past where there were few adequately trained therapists, the knowledge that many withlymphedema still go untreated and do not have access to proper care.It was the knowledge that our treatments worked and decreased morbidity and mortality. That our knowledge and a few products hadthe ability to reach out and do small things with great love as we treated someone with lymphedema.

So we held our press conference and made our points. Physicians, therapists, and passionate backers, all with the common goal of improving lymphedema care in our country. We took our passion to the senators and congressmen on Capital Hill. I was surprised how openly we were received in their offices, mostly full of young energetic staff full of optimism. I was impressed how they listened to our plight with interest and took notes and made full effort to understand the situation. I left with a completely restored faith in our democratic system, despite all its faults and interparty bickering which often dominates the news.

By the end of the trip, we had secured a key senator to sponsor a bill and reverse the ruling, and met with senior health care policymakers who could help make this happen. It was as if someone above was watching our small band of warriers for a cause and guiding our small voices so they could be heard.

There is much still to be done, and it must be done quickly. We need patients and therapists to write and visit their senators and congressmen and raise awareness of this issue. If the ruling is not overturned this session, it will require going through the Congressional Budget Office, which complicates the bill and slows the timing to pass the reversal. Still, at this point I am optimistic that a quick reversal is very possible, and the optimist inside me insists it will happen soon.

With these thoughts, I look to our future as therapists, patients and physicians. I see great possibilities if we can correct this injustice and right this wrong. I see the ability for us to move forward in improving standard-of-care, and not backwards.

I see hope for the future to develop a more structured certification training process so we can ensure standard-of-care for all patients. I see hope that the NLN will be able to take a leadership role in promoting this standard-of-care, and advancing it as our knowledge and treatment ability increases.

Along with this, I hope to see mended fences and a continued focus on serving our patients as humble servants to their plight -- working in our own Mother Theresa like way to do small things with great love as we care for our patients.

Lymphedema Stakeholders

Lymphedema Stakeholders PAC

A new political action committee has been formed to represent lymphedama patients and to support legislative acitivities on our behalf at the Federal level. It is imperative that we as lymphedema patients be proactive on our own behalf and to push for comprehensive legislation at both the state and Federal levels that will insured our rights to treatment according to accepted protocols and that lymphedema be recognized as a chronic and serious medical condition.

I am a member of the PAC and totally support and encourage itts efforts.

From the homepage:

Who Are We?

Lymphedema Stakeholders Political Action Committee is a non-profit organization (501C4) formed to protect the rights of all lymphedema patients.

Our Mission

The mission of the Lymphedema Stakeholders PAC is to advance the quality of care for lymphedema patients, and to protect patients' rights to comprehensive lymphedema therapy from providers who meet standards established by the Lymphology Association of North America (LANA).

Visit their website at:

Lymphedema Stakeholders

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One of the first tasks facing the Coalition was to fight to stop changes in the Medicare rules that would greatly limit our access to this treatment, called manual decongestive therapy.

This page will give background on these rulings and how they will affect us.

Limits to Manual Lymph Drainage in the Treatment of Lymphedema

The Coalition has also joined has with a much larger, broad based healthcare coalition devoted to preserve patient access to physical medicine and rehabilitation.

Read about this organization:

The Coalition to Preserve Patient Access to Physical Medicine and Rahabilitation

On November 16, 2005, the groups hed a press conference in Washington DC outlining our concerns and subsequently also met with numerous Federal legislators:

Press Conference

Again, I urge all lymphedema patients, therapists, healthcare providers, families and friends to support this venture.

Together we can make a difference.

Lymphedema Related Infections

Lymphedema Types of Infections

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Related Infections: Cellulitis, Lymphangitis, Lymphadenitis, Erisypelas, Impetigo, Cat Scratch Fever, Cutaneous Abscesses, Scalded Skin Syndrome

I feel it is important to have an understanding of the various types of infections that we face with lymphedema.These infections includecellulitis, lymphangitis, and erysipelas.

One must remember that every infection we have further damages our lymphatics, thus leading to more severe lymphedema. Untreated infection will lead to sepsis (commonly refered to as blood poisoning), gangrene which involves loss of limb and/or eventual death.

In treating any type of infection, the doctor not only must identify the type of bacteria involved, but must understand the staging of lymphedema and the differences in the tissue types of the stages.

Heavily fibrotic lymphedema limbs are exceedingly difficult to treatbecause the denseness of the tissue impeeds or even can prevent the chosen antibiotic from reaching the bacteria. In this situationlong term IV antibiotic thereapy should be considered.

Our Home Page: Lymphedema People

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Cellulitis

Cellulitis is an acute inflammation of the connective tissue of the skin, caused by infection with staphylococcus, streptococcus or other bacteria.See the Lymphedema Cellulitis and Lymphangitis Section for more comprehensive information.

Acute Cellulitis is one of the complications of lymphedema. The patient may not be aware of the source of the etiology. Sometimes it may be a cut, mosquito bite, open wound or other infection in the body.

The first sign is increased or different quality of PAIN involving the lymphedema limb. The patients often describe this as a "flu like symptom or an ache" involving the Lymphedema arm or leg. This is usually followed by sudden onset of ERYTHEMA(redness, red streaks or blotches) on the involved limb. The HYPERTHERMIA(lymphedema limb becomes warm, hot) will follow and the patient may experience the CHILLS and even HIGH FEVER.

The early intervention and treatment with antibiotics will resolve this condition (it usually takes a very minimum ten day course of antibiotics). Only a Medical Doctor will be able to prescribe the Antibiotics, thus a consultation with a Doctor is necessary. Severe Cellulitis may require Inter venous Antibiotic treatment and hospitalization. Again, elevation of the affected limb is important.

During that phase the patient should NOT massage the Lymphedema limb, bandage, apply the pump, wear tight elastic sleeve or exercise excessively. Avoid the blood pressure and blood to be drawn from the involved arm. Keep the limb elevated as much as possible while resting. Once the symptoms dissipate the treatment MLD/CDP should be initiated.How do we prevent this infection? The patient should be careful with daily activities and take all precautions to protect the skin (wear gloves when gardening, cleaning with detergents, etc... ). If an injury to skin occurs on the Lymphedema limb it is necessary to clean the wound with alcohol or hydrogen peroxide and apply Neosporin/Polysporin antibiotic ointment. If the symptoms progress seek the attention of a physician immediately.

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Lymphadenitis and lymphangitis

Lymphangitis is an inflammation of one or more lymphatic vessels. Generally caused by an acute streptoccocal infection from an insect bite,animal bite of wound. Fine red streaks may extend from the infected area to the armpits or groin. Other signs and symptoms include fever, chills, headache, or muscle ache.Immediate treatment is required to prevent the infection spreading into the blood stream thereby becoming septic. Treatment is with antibiotic therapy.

Lymphangitis

Lymphangitis involves the lymph vessels/channels, with inflammation of the channel and resultant pain and systemic and localized symptoms. It commonly results from an acute streptococcal or staphylococcal infection of the skin (cellulitis), or from an abscess in the skin or soft tissues.

Lymphangitis may suggest that an infection is progressing, and should raise concerns of spread of bacteria to the bloodstream, which can cause life-threatening infections. Lymphangitis may be confused with a clot in a vein (thrombophlebitis).

Symptoms

red streaks from infected area to the armpit or groin
may be faint or obvious
throbbing pain along the affected area (common)
may involve the lymph nodes (see above)
fever of 100 to 104 degrees Fahrenheit and/or chills
individuals may have a general ill feeling (malaise), with loss of appetite, headache, and muscle aches

Complications

abscess formation
cellulitis
sepsis (generalized or bloodstream infection)
fistula formation (seen with lymphadenitis due to tuberculosis)

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Lymphangitis

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Lymphadenitis and lymphangitis

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Acute Lymphangitis

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Acute lymphangitis

Acute lymphangitis is a bacterial infection in the lymphatic vessels which is characterized by painful, red streaks below the skin surface. This is a potentially serious infection which can rapidly spread to the bloodstream and be fatal.

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Lymphadenitis and Lymphangitis

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Lymphadenitis

Inflammation of lymph nodes.

Etiology

Any pathogen--bacterial, viral, protozoal, rickettsial, or fungal--can cause lymphadenitis. Lymph node involvement may be generalized, with systemic infection, or confined to regional lymph nodes draining a local area of infection. Generalized lymph node enlargementis common in infectious mononucleosis, cytomegalovirus infection, toxoplasmosis, brucellosis, secondary syphilis, and disseminated histoplasmosis. Regional lymphadenopathy is prominent in streptococcal disease, TB or nontuberculous mycobacterial disease, tularemia, plague, cat-scratch disease, primary syphilis, lymphogranuloma venereum, chancroid, and genital herpes simplex.

Symptoms, Signs, and Diagnosis

Lymph node enlargement from edema and WBC cellular infiltration, the major sign of lymphadenitis, may be asymptomatic or may cause pain and tenderness. With some infections the overlying skin is inflamed, occasionally with cellulitis; abscess formation may occur, and penetration to the skin will produce draining sinuses.
Lymphadenitis and its cause are usually clinically apparent. Occasionally, however, lymph node aspiration and culture or excisional biopsy is necessary.

Treatment

Treatment depends on the underlying cause. With resolution of the primary process, lymph node enlargement usually resolves, but firm, nontender lymphadenopathy sometimes persists. Hot, wet dressings may help relieve symptoms of acutely painful lymph nodes. Abscesses require surgical drainage.

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Lymphadenitis

Definition

Lymphadenitis is the inflammation of a lymph node. It is often a complication of a bacterial infection of a wound, although it can also be caused by viruses or other disease agents. Lymphadenitis may be either generalized, involving a number of lymph nodes; or limited to a few nodes in the area of a localized infection. Lymphadenitis is sometimes accompanied by lymphangitis, which is the inflammation of the lymphatic vessels that connect the lymph nodes.

Description

Lymphadenitis is marked by swollen lymph nodes that are painful, in most cases, when the doctor touches them. If the lymphadenitis is related to an infected wound, the skin over the nodes may be red and warm to the touch. If the lymphatic vessels are also infected, there will be red streaks extending from the wound in the direction of the lymph nodes. In most cases, the infectious organisms are hemolytic Streptococci or Staphylococci. Hemolytic means that the bacteria produce a toxin that destroys red blood cells.

The extensive network of lymphatic vessels throughout the body and their relation to the lymph nodes helps to explain why bacterial infection of the nodes can spread rapidly to or from other parts of the body. Lymphadenitis in children often occurs in the neck area because these lymph nodes are close to the ears and throat, which are frequent locations of bacterial infections in children.

Causes and symptoms

Streptococcal and staphylococcal bacteria are the most common causes of lymphadenitis, although viruses, protozoa, rickettsiae, fungi, and the tuberculosis bacillus can also infect the lymph nodes. Diseases or disorders that involve lymph nodes in specific areas of the body include rabbit fever (tularemia), cat-scratch disease, lymphogranuloma venereum, chancroid, genital herpes, infected acne, dental abscesses, and bubonic plague. In children, tonsillitis or bacterial sore throats are the most common causes of lymphadenitis in the neck area. Diseases that involve lymph nodes throughout the body include mononucleosis, cytomegalovirus infection, toxoplasmosis, and brucellosis.

The early symptoms of lymphadenitis are swelling of the nodes caused by a buildup of tissue fluid and an increased number of white blood cells resulting from the body's response to the infection. Further developments include fever, often as high as 101-102°F (38-39°C) together with chills, loss of appetite, heavy perspiration, a rapid pulse, and general weakness.

Diagnosis

Physical examination

The diagnosis of lymphadenitis is usually based on a combination of the patient's history, the external symptoms, and laboratory cultures. The doctor will press (palpate) the affected lymph nodes to see if they are sore or tender. Swollen nodes without soreness are often caused by cat-scratch disease. In children, the doctor will need to rule out mumps, tumors in the neck region, and congenital cysts that resemble swollen lymph nodes.

Although lymphadenitis is usually diagnosed in lymph nodes in the neck, arms, or legs, it can also occur in lymph nodes in the chest or abdomen. If the patient has acutely swollen lymph nodes in the groin, the doctor will need to rule out a hernia in the groin that has failed to reduce (incarcerated inguinal hernia). Hernias occur in 1% of the general population; 85% of patients with hernias are male.

Laboratory tests

The most significant tests are a white blood cell count (WBC) and a blood culture to identify the organism. A high proportion of immature white blood cells indicates a bacterial infection. Blood cultures may be positive, most often for a species of staphylococcus or streptococcus. In some cases, the doctor may order a biopsy of the lymph node.

Treatment

Medications

The medications given for lymphadenitis vary according to the bacterium or virus that is causing it. If the patient also has lymphangitis, he or she will be treated with antibiotics, usually penicillin G (Pfizerpen, Pentids), nafcillin (Nafcil, Unipen), or cephalosporins. Erythromycin (Eryc, E-Mycin, Erythrocin) is given to patients who are allergic to penicillin.

Supportive care

Supportive care of lymphadenitis includes resting the affected limb and treating the area with hot moist compresses.

Surgery

Cellulitis associated with lymphadenitis should not be treated surgically because of the risk of spreading the infection. Pus is drained only if there is an abscess and usually after the patient has been started on antibiotic treatment. In some cases, a biopsy of an inflamed lymph node is necessary if no diagnosis has been made and no response to treatment has occurred.

Prognosis

The prognosis for recovery is good if the patient is treated promptly with antibiotics. In most cases, the infection can be brought under control in three or four days. Patients with untreated lymphadenitis may develop blood poisoning (septicemia), which is sometimes fatal.

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Erysipelas

Erysipelas is a superficial bacterial skin infection skin generallycaused by Strep A bacteria. It can spread with alarming rapidity asit invades the cutaneous lymphatics.While some classify it as a "form of cellulitis," it actually can be differentiated by the clear lines of demarcation of the infection.Symptoms include marked lines of infection, fever, pain, an overall achy feeling and swollen lymph nodes. Most cases involve the legs, and the second largest number of cases involve the face.Like any type of infection a lymphedema patient experiences, antibiotic treatment needs to start immediately so as to prevent septicemia or bacteremia.

Erysipelas

Synonyms and related keywords: group A beta-hemolytic streptococci, hemolytic streptococcus

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Erysipelas

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Erysipelas

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Erysipelas

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Erysipelas Also includes images

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Impetigo

An bacterial infection of the skin beginning as a redness and progressing to itching, blisters, breakdown of the skin, and honey-colored crusts. Lesions usually form on the face and spread locally. The disorder is highly contagious by contact with the discharge from the lesions. Acute kidney trouble is an occasional complication. Treatment includes thorough cleansing with antibacterial soap and water, compresses, removal of crusts and use of systemic antibiotics. Treatment is essential to prevent spread of infection.

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Impetigo

Definition:

Impetigo is a skin disorder caused by bacterial infection and characterized by crusting skin lesions.

Causes, incidence, and risk factors

Impetigo is a common skin infection. It is most common in children, particularly children in unhealthy living conditions. In adults, it may follow other skin disorders. Impetigo may follow a recent upper respiratory infection such as a cold or other viral infection. It is similar to cellulitis, but is more superficial, involving infection of the top layers of the skin with streptococcus (strep), staphylococcus (staph), or both.

The skin normally has many types of bacteria on it, but intact skin is an effective barrier that keeps bacteria from entering and growing within the body. When there is a break in the skin, bacteria can enter the body and grow there, causing inflammation and infection. Breaks in the skin may occur with insect bites, animal bites, or human bites; or other injury or trauma to the skin. Impetigo may occur on skin where there is no visible break.

Impetigo begins as an itchy, red sore that blisters, oozes and finally becomes covered with a tightly adherent crust. It tends to grow and spread. Impetigo is contagious. The infection is carried in the fluid that oozes from the blisters. Rarely, impetigo may form deeper skin ulcers.

Symptoms

Skin lesion on the face/ lips, or on the arms or legs, spreading to other areas. Typically this lesion begins as a cluster of tiny blisters which burst, followed by oozing and the formation of a thick honey or brown colored crust that is firmly stuck to the skin.

Itching blister:
Filled with yellow or honey-colored fluid
Oozing and crusting over
Rash (may begin as a single spot, but if child digs at it, it may spread to other areas).
In infants, a single or possibly multiple blisters filled with pus, easy to pop and when broken leave a reddish raw-looking base.

Lymphadenopathy -- local lymph nodes near the infection may be swollen.

Signs and tests

Diagnosis is based primarily on the appearance of the skin lesion. A culture of the skin or mucosal lesion usually grows streptococcus or staphylococcus.

Treatment

The goal is to cure the infection and relieve the symptoms.

A mild infection is typically treated with a prescription antibacterial cream such as Bactroban. Oral antibiotics (such as erythromycin or dicloxacillin) are also frequently prescribed and result in rapid clearing of the lesions.

Wash the skin several times a day, preferably with an antibacterial soap, to remove crusts and drainage.

Prevent the spread of infection. Use a clean washcloth and towel each time. Do not share towels, clothing, razors, and so on with other family members. Wash the hands thoroughly after touching the skin lesions.

Expectations (prognosis)

The sores of impetigo heal slowly and seldom scar. The cure rate is extremely high, but they often come back in young children.

Complications

The infection could spread to other parts of the body. This is common.
Children often have multiple patches of impetigo.
A systemic infection could lead to kidney failure (post-streptococcal glomerulonephritis). This is a rare occurrence.
Permanent skin damage and scarring (also extremely rare).
PreventionGood general health and hygiene help to prevent infection. Minor abrasions or areas of damaged skin should be thoroughly cleansed with soap and clean water. A mild antibacterial agent may be applied if desired.Impetigo is contagious, so avoid skin contact with drainage from impetigo lesions.

Update Date: 4/15/2003

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Impetigo

Medline Plus

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Impetigo

Skinsite.com

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Impetigo

Medicine Last Updated: April 24, 2002

Synonyms and related keywords: impetigo contagiosa, group A beta-hemolytic streptococci, GABHS, Staphylococcus aureus, bullous impetigo, impetigo bullosa, common impetigo, folliculitis, follicular impetigo, ecthyma

Author: Randy Park, MD, Chair, Associate Professor, Department of Emergency Medicine, Denton Regional Medical Center

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Impetigo

New Zealand DermnetImages

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Impetigo

Netdoctorco.uk

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Impetigo Fact Sheet

Community Health Administration - Maryland

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Impetigo Compendium of Images - Dermatlas

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Cat Scratch Fever

I have included cat scratch fever in the list of types of infections because of the number of cats people have as pets. Lymphedema patients ar particularly susceptible due to the localized immuno-deficiency of the lymphodemous limb.Cat scratch fever is an infection that actually may be caused by either a virus or a bacteria. It results from either the bite or scratch of a cat that my otherwise look healthy. They are simply carriers of the virus/bacteria. The first signsare swelling and bumps filled with pus near the scratch. Lymph nodes in the neck, head and groin, o armpits begin swelling with two weeks. The symptoms can last for months.

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What is cat scratch fever disease?

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Cat-scratch Disease (lymphoreticulosis)

Lymphoreticulosis Symptoms.

EVERYTHING, THAT YOU WANTED TO KNOW ABOUT CATSCRATCH DISEASE (lymphoreticulosis), lymphoreticulosis SYMPTOMS. EFFECTIVE TREATMENT OF CAT-SCRATCH DISEASE.

Extractions: Cat-scratch disease (benign lymphoreticulosis) – infectious disease associated with a history of scratches, bites from or close contact with a cat. The infecting agent is Bartonella henselae a tiny bacillus of familia Chlamydiae. The host and the source of infection are cats, with the infection agent being a normal part of their mouth flora. Person-to-person transmission of the disease has not been shown. The infection enters through skin wounds causing inflammation. Carried by lymph the infection reaches the nearest lymph node causing its inflammation too. Further the infection spreads with the bloodstream over the system. After convalescence the body develops persistent immunity to the disease. Treating cat-scratch disease (lymphoreticulosis). Symptoms of cat-scratch disease . Incubation period lasts from 3 to 20 days. A small, slightly elevated stain, slightly painful with a red rim appears in the place of the healed scratch or bite, turning in 2-3 days into a vesicle filled with a turbid content. The vesicle is then replaced by a small ulceration or crust. In several days after the scratch was inflicted the nearest lymph node gets enlarged. At this time the patient may complain of a headache, malaise, temperature. In some cases temperature may rise to 38-39 C and be associated with morning-night fluctuations and sweating, though in 7-10 days the temperature drops back to normal or slightly above. Sometimes the fever becomes tidal. Rarely high temperature may persist for 5-6 months and longer. Sometimes the disease progresses without temperature rise. The affected lymph node after reaching its maximum slowly diminishes, seldom purulent maturations end up with spontaneous opening and pus discharge.

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Cat Scratch Disease

eMedicineLast Updated: December 30, 2003Synonyms and related keywords: CSD, cat-scratch disease, Parinaud oculoglandular disease, kitten scratch disease, la maladie des griffes du chat, benign inoculation lymphoreticulosis, benign inoculation reticulosis, catscratch fever, cat-scratch fever, regional granulomatous lymphadenitis

Author: Joseph R Lex, Jr, MD, Assistant Professor, Department of Emergency Medicine, Temple University Hospital

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Cat Scratch Disease

Dr Greene.com

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Cat Scratch Disease

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Cat Scratch Fever TKH Bacteriology - Tara K. Harper

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Cutaneous Abscesses

Localized pus filled infections. More commonly referred to as carbuncles, boils, folliculitis, and furnuncles.

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Cutaneous Abscesses

Alternative Names

abscess - skin; cutaneous abscess; subcutaneous abscess

Definition

A collection of pus and infected material in or on the skin

Causes, Risk Factors Incidence

Skin abscesses are fairly common. They are caused when a localized infection causes pus and infected material to collect in the skin or subcutaneous tissue. Skin abscesses may follow a bacterial infection, commonly an infection with staphylococcus (staph aureus is most common). They can develop after a minor wound, injury, or as a complication of folliculitis or boils (furuncles, carbuncles). Skin abscesses may occur anywhere on the body. They affect people of all ages.The abscess can obstruct and impinge on the functioning of deeper tissues. The infection may spread locally or systemically. The spread of infection through the bloodstream may cause severe complications.

Prevention

Prevent and watch for bacterial infections. Keep the skin around minor wounds clean and dry. Consult the health care provider if you develop signs of infection, including fever, pain, redness, localized swelling, or drainage that looks like pus or is bloody. Treat superficial (minor) infections promptly.

Symptoms

skin lesion
open sore or nodule
reddened
may drain fluid
localized swelling, induration
affected area is tender to touch

Signs and Tests

The diagnosis is based on the appearance of the area.Culture of drainage from the lesion may reveal the causative organism.

Treatment

The goal of treatment is the cure of the infection.Surgical incision and drainage of the abscess, with or without packing for 24 to 48 hours, cleans the area and allows infection to be controlled. Some skin abscesses may be drained in the health care provider's office.Antibiotics are given to control the infection.Heat (such as warm compresses) may speed healing, reduce inflammation, and reduce discomfort.Elevate the affected part to reduce swelling and inflammation.

Prognosis

Most skin abscesses are curable with treatment.
Complications
localized spread of infection
impingement on the functioning of adjacent structures
gangrene (tissue death)
systemic spread of infection causing:
endocarditis
osteomyelitis
multiple new abscesses ("seeding" of infection)
abscess formation on the joints, pleura, or other locations

Call you doctor if

Call for an appointment with your health care provider if symptoms indicate skin abscess is present.Call for an appointment with your health care provider if signs of superficial skin infection occur, including fever, pain, redness, localized swelling, drainage that looks like pus or is bloody.Also call for an appointment with your health care provider if new symptoms develop during or after treatment for skin abscess.

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Cutaneous Abscesses

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Necrotizing Subcutaneous Infections

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Scalded Skin Syndrome

Skin infection caused by staphlococcal bacteria. Appearance ischaracterised by red peeling skin. It is causd by the release of two toxins (epidermolytic toxins A and B) of from toxigenic strains of the bacteria Staphylococcus aureus.

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Staphylococcal scalded skin syndrome

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Staphylococcal Scalded Skin Syndrome

Last Updated: December 3, 2002

Synonyms and related keywords: SSSS, exfoliative dermatitis, toxin-mediated staphylococcal syndromes, Staphylococcus aureus, S aureusAuthor: Jessica Kim, MD, Staff Physician, Dermatology Service, Madigan Army Medical Center

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Self-Pity

Do you rise and shine or rise and whine?

Are you, or do you know, someone who starts the day by rising and whining instead of rising and shining? You know the type; they love to swish around in self-pity. They believe the world is unfair and the only thing preventing them from enjoying it are their particular ‘problems.’

What makes feeling sorrow for oneself so insidious is that it is a sign of both unhappiness and the fact that the misery will continue. How does one become trapped in a morass of self-pity? It begins with self-doubt. When we fail to believe in ourselves, we fail to reach our potential. And by not reaching the success we deserve, we experience the psychological pain of regret, shame, and guilt. Now, what would you do if you accidentally touched a hot stove? Wouldn’t you pull your hand away? We automatically flee from or avoid pain. The same is true with psychological pain.

It may be too painful to admit I am not as successful or happy as I would like to be because I have either done the wrong things or haven’t done the right things. So, rather than feel that pain, I cover it up by denying responsibility and assigning blame for my misery to the outside world. In other words, we don’t practice self-pity to feel good, but to avoid feeling pain. So, you see, though feeling sorry for others is an expression of compassion; feeling sorry for ourselves is a cover-up, a form of self-deception.

So, how do we crawl out of the mire of self-pity and get on with the rest of our lives? Before sharing some ideas, let me first say that the purpose of the following suggestions is to help you, if any of it applies; it is not to be used to judge others. The reason for this is that we can never know what is going on in the minds of others. What you see as self-pity in others could in fact be legitimate feelings due to grief, clinical depression, or a major illness. One more point, all attributes, whether negative or positive, are shared in common. As a human, I am bound to experience self-pity at one time or another, and the amount that I experience will be greater or lesser than others. Because of the commonality that binds us, we probably could all benefit by the following suggestions.

1. Rather than run from the pain that’s troubling you, face it and use it as a catalyst for change. Use your misery as motivation for self-improvement. Find out what you are doing wrong and correct your behaviour. Become angry at your own self-defeating actions and do something about it. Yes, it’s as simple as that. Although it’s simple, change does involve more pain (no pain, no gain) because of the effort you have to make. But this type of pain is to be welcomed, for it will dissolve your misery and restore your happiness.

2. Don’t add to your suffering by comparing yourself to others. Life is not a competition; it is a garden. Every flower (person) is different but beautiful in it’s own way.

3. Stop being demanding. Stop believing the world was created to serve you. The truth is, you were created to serve it. It doesn't center around you. You're just a small (but important) part of the whole. Focus on what you can give back to life instead of what you can take from it. Make your contribution and enjoy the ride. Some whiners complain, "What's the purpose of it all? What's in it for me?" They find no meaning because they are self-centered and can't understand why the world doesn't cater to their every need. When they stop thinking of themselves they will discover meaning, for there is a whole world out there that needs their help in spreading joy.

4. Admit that many people are worse off than you; yet, they are doing better. So, follow their example and join their ranks.

5. Stop claiming the world is unfair. The only thing unfair is your distorted belief that the successes of others are due to their 'lucky breaks' and good fortune rather than their constructive action. Once you stop whining and start taking action, you will be able to join them in success.

6. True, some situations are more difficult than others, but beware of giving in to hopelessness and seeking comfort in chronic self-pity. For example, a woman married to an alcoholic that beats her five children will find it difficult to survive on her own. But for the safety of her children, she needs to let go of her fear, calmly study her options, make plans, and follow the best path available at the time, slowly working her way upward.

7. Realize that there are no failures on the road to success; there are merely a series of successive steps that must be taken and detours that must be maneuvered. 'Failure' is a term that negative thinkers attach to those steps and detours. Just as a stranger is a friend you have yet to make, ‘failure’ is a success you have yet to reach, so just keep plodding onward.
8. Understand that misery doesn't exist in the world, but in our mind. It is not our present conditions, but our reactions to those conditions that are the source of our pain. The fault lies in us. Self-pity is self-defeating; no good can come out of it, so accept responsibility and change yourself.

9. Change your focus from what you cannot do to what you can do, from what you lack to what you have, from the way things are to the way you will make them become, from the person you are to the person you plan to be, from the problems facing you to their possible solutions, and from the difficulties you're mired in to the opportunities they offer. Since we become what we think about, it is essential that we focus on the right things.

10. Use the power of your imagination to help, not hinder you. Don't accept your imagination's exaggeration of the magnitude of your problems, for if you do, you become its slave, paralyzed by fear and self-doubt. Instead, use your imagination to vizualize how wonderful things will be when you begin taking constructive action. By doing so, your imagination will become your coach, motivating you to act.

11. Change paths. Leave the Path of Self-Pity for the Path of Positive Action. Do this by asking yourself, "WHAT DO I WANT FROM LIFE? Do I want to be happier?” If so, you need to ask the next question, which is, "WHAT AM I GOING TO DO ABOUT IT?"

12. Finally, understand the power of choice. Choice is a door. When we open one, we slam shut another. When we open the door of Self-Pity, we slam shut the doors of Positive Action, Success, and Happiness.

Self-pity is never a helpless cause because it can always serve as a terrible example. The choice is ours, we can serve as an inspiration to others by illustrating what is possible, or we can serve as an example of what NOT to do. Which will it be? Which door will we open?

© Chuck Gallozzi, Self-Pity

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Lymphedema People

Learning to Accept Yourself

We are not born doubting ourselves. We learn to do it. In fact, we are usually taught to doubt ourselves. Often we are taught to do so by otherwise well-meaning people who are passing along their own doubts and uncertainties and who believe they are being protective and caring. What these people (usually parents and other significant adults) want are strong, capable and self-confident people, but they often inadvertently teach us thought processes that lead to something else. That’s the bad news. The good news is that we can understand some of these processes and learn new ways of coping that allow us to become more accepting of ourselves. Following are six behaviors you may have learned that can be unlearned and allow you to move toward greater self-acceptance.

Moralistic Self-Judgment

One way to really dislike yourself is to always judge yourself in a very moralistic way. People often spend a lot of time and energy labeling their behavior with moral adjectives such as "bad," "hateful" and "mean." When you apply these kinds of words to yourself you make liking yourself much more difficult. There is a more productive way of looking at yourself that will allow you to begin to like yourself more. Instead of evaluating yourself in this moralistic way, begin to ask questions like: "Did I do what I really wanted to do in this situation?" "How can I correct the misunderstanding that occurred?" In other words, you can start to view what you've done as productive or non-productive rather than as good or bad. If something is non-productive, you can focus on what you have learned from it and try another approach that might be more productive.

Over-Generalizing

Another thing that might cause you not to accept yourself is over-generalizing about something you’ve done that you don’t like. So, for example, if you fail a test you might generalize and say, "I’m really a stupid person." When you do this you are making a statement about all of you all of the time and not just about this one situation at this time. Instead, you might decide that your grade on this test in this subject at this time was indeed poor, and then go on to decide what you want to do about your poor grade, if anything. Getting stuck in over-generalizing discourages you from taking steps that might allow you to do better on the next exam and builds an expectation of future failure.

Impossibly High Standards

Having standards that are impossibly high is a third way you can not accept yourself. It may not come as a surprise to you that most of us are more demanding of ourselves than we are of others. Somehow we can tolerate the fact that other people fail, that they aren’t always kind, that they’ve done things they aren’t proud of, but we have difficulty accepting those very human aspects of ourselves. The need to be perfect is another way to set yourself up for failure and enhance the feeling that you are not acceptable. We all make mistakes. Accepting less than perfection simply means recognizing the limitations inherent in being born a human being. Learn to value who you are rather than who you could become if you were to do everything you can imagine doing and doing those things perfectly. To quote Linus, a sober and often worried character from a popular comic strip, "The world’s heaviest burden is a great potential." The good news is that we don’t always have to choose to try to live up to our "great potential." Wouldn’t it be overwhelming if we always had to do what we imagine we could do? Nobody has the time and energy to do all of that. We must make choices about what we will pursue and do them the best we can under the circumstances (which aren’t always ideal, by the way).

Not Accepting that there are Real Limits to Your Abilities

The idea that you should always be able to attain your goals as long as you work hard enough is another factor interfering with self-acceptance. You will reach many of your goals and should give yourself credit for having done so. Some of us have trouble seeing our successes because we focus so much on our failures and many times the failures come after a lot of hard work and personal suffering. It seems that all that hard work should pay off in our having reaching the goal we set out to achieve. It is hard to accept that a given goal may be out of our reach and that may be because of many factors, including the fact that we may not have the talent or skill needed to reach the goal. Of course there may be other factors in operation that make the achieving of that goal at that time impossible—health concerns, financial problems, family difficulties, extraneous stressors, or any number of other factors acting alone or together. The real trick to self-acceptance is to see that the goal is unattainable, at least for now, and shifting your focus to accomplishing what you can accomplish under the circumstances. That could include evaluating your original goal and deciding whether or not to continue with it. It also means giving yourself credit for what you have accomplished and what you have learned from your experiences.

The Comparison Trap

Judging yourself by what others have accomplished is a sure way to lower your self-acceptance. Have you noticed that you never compare yourself to people who seem to aspire to less than you do and that you always chose those people who are the top performers or the most popular as your yardstick for success? Are you as good as your friends, you brother or sister, your parents or Joe Blow? And how about trying to be like "normal" people are? (And who or what determines what is "normal"?) Can you only be good if you’re better than someone else? When we use other people as our yardstick, we aren’t taking into consideration our own personal limitations or talents. For example, if someone seems to be more articulate than you, you can respond in one of two ways: You can become upset and depressed by telling yourself that you should be as articulate as that person, or you can recognize and accept the fact that there are probably a lot of people out there who are more articulate than you at certain times and under certain circumstances and that is OK. It doesn’t mean a thing about you. Playing the comparison game is a dead end street. By doing that you are probably missing some other qualities by which you can judge your own worth, like your honesty, friendliness, caring nature, dedication and so forth. And really, people don’t value you for how much you are like someone else. They do value you for the ways you are being you.

Passivity

Just passively letting your life happen may make it more difficult to accept yourself. Part of accepting yourself is engaging in activities that help you like yourself. Think back to those times when you weren’t concerned about your acceptability. What kinds of things were you doing? How were you spending your time? To accept and like yourself means that you approve of how you are living your life. If you aren’t accepting yourself, you probably don’t like the activities you’re engaged in. You are feeling dissatisfied. A way to increase your self-acceptance is to become more actively engaged in your life. Look for those activities and relationships that give you the most enjoyment—not necessarily the most enjoyment you could possibly have, but the most you can get from your choices at the moment. Try new things, perhaps things you have always wanted to try but didn’t because you felt you couldn’t do them. Try them with the attitude that you want to know what it would actually be like to do them. You may find that they are enjoyable and that you want to continue them. You may find that they are OK, but not worth continuing. You may find that you don’t like them at all and feel fine about crossing them off your list of things to do. Trying and getting real experience is a way of feeling better about yourself and gaining more confidence in your abilities.

Summary

To feel better about yourself, stop moralistically evaluating your behavior. Rather than condemning yourself, ask yourself what you have learned. Second, stop over-generalizing. When you do make a mistake, view it as a situation-specific, not as a statement of about all of you as a person. Third, resist the temptation to set unrealistically high goals. You are sure to fail if your goals are too high. Fourth, remember that it is an illusion to believe that you will always get what you want to get. You need to accept that you are human have all of the normal human failings. Fifth, avoid using others as the yardstick by which you judge yourself. Don’t get into the trap of saying: "I’m only good if I’m as good as, or better than, someone else." And last, become actively involved in your life. Do things that make you feel good about yourself and experiment with finding new activities that you actually try, rather than just imagining what it would be like to do them.

Learning to Accept Yourself

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Lymphedema People

Pregnancy and Lymphedema

Lymphoedema and Pregnancy

By Professor Peter Mortimer, LSN Chief Medical Advisor andDr Sahar Mansour, Consultant Clinical Geneticist, St. George's Hospital, London

Changes in a Normal Pregnancy

The cardiovascular system undergoes considerable changes during pregnancy with an increase in blood output from the heart by at least 50%. Blood vessels generally enlarge creating a relatively 'under filled' circulation and so to compensate, the kidneys try and conserve salt and water. This leads to fluid retention amounting to some 6-8 litres in the body. The dilution of the plasma proteins encourages fluid to leak from the blood vessels into the tissues. A fall in the threshold of the hormone that encourages a fluid diuresis maintains a fluid retention state. By the end of the pregnancy, 80% of healthy women will have some degree of oedema.

Very little is known about what happens to the lymphatic system during pregnancy. If blood vessels enlarge, i.e. relax, then by implication, lymphatic vessels are likely to do the same, in which case they will not be as efficient at draining fluid. Normally there is sufficient reserve in lymphatic transport so that any increases in tissue fluid will be compensated for by increases in lymph drainage. If the lymph drainage is already working close to capacity because of a genetic or constitutional weakness in the lymphatic system (but not so severe as to have produced lymphoedema before), then the extra demands of pregnancy may be all that is needed to manifest swelling for the first time.

Other factors that potentially increase the risk of oedema during pregnancy are weight gain and a reduction in exercise levels.While fluid retention will increase weight, so will obesity. Lean women who eat to appetite gain as much as 1kg in the first 10 weeks and women with a tendency to obesity will gain much more. Such weight gain will probably have an adverse effect on lymph drainage, particularly in the legs. It is difficult to maintain exercise levels during pregnancy because of tiredness and the awkwardness the pregnancy brings to walking. Exercise is, of course, crucial for good lymph drainage in the legs. Like other blood vessels, the veins in the leg tend to enlarge during pregnancy. Varicose veins often develop, which will result in a further filtration of fluid from the blood into the tissues of the leg and so make oedema worse.

Pre-eclampsia

Pre-eclampsia (used to be called toxaemia of pregnancy) is specific to pregnancy and manifests with hypertension (raised blood pressure), a leak of protein by the kidney, and oedema. The cause is not known, but the syndrome of pre-eclampsia usually develops from the mid-point in the pregnancy (20 weeks onwards), and resolves completely after delivery. Generalised oedema is an inconsistent feature. It may develop suddenly and is associated with accelerated weight gain (due to fluid retention). Although the ankles and feet will be the commonest site for the swelling due to the effects of gravity, oedema can occur anywhere in the body including the chest and the abdomen (ascites is free fluid in the abdominal cavity). The generalised nature of the oedema would suggest that the fault lies with the blood vessels leaking more fluid into the tissues rather than any failure of the lymphatic system, but nobody knows. As mentioned earlier, any such increase in tissue fluid will inevitably demand more of the lymphatic vessels to drain the fluid and any failure to do so will increase the oedema further. Diuretics are best avoided in pregnancy because they result in an even greater 'under fill' of the blood circulation. Drugs called 'calcium channel blocking agents' are recommended for the raised blood pressure, but do tend to interfere with the working of lymphatic vessels and may increase ankle oedema.

Lymphoedema in Pregnancy

A major concern of any young female patient with lymphoedema is "What will happen to my lymphoedema if I become pregnant?" The answer is that it is likely to get worse because of the fluid retention, but it should be manageable and fully recover once the baby is born. The extra bodily fluid retained during the pregnancy will include the part of the body affected by the lymphoedema; so extra effort will be required to ensure that this extra fluid is drained by the local lymphatic system that is already failing. So if a leg is affected by lymphoedema, for example, then extra measures to control the swelling may be necessary. These measures may include longer periods of rest with the leg elevated, manual lymphatic drainage, or an additional compression garment. Not every woman with lymphoedema suffers any exacerbation of swelling during pregnancy. In many, the lymphoedema remains unaffected, and so what is described here is the worst case scenario.

There is no reason to believe pregnancy harms the lymphatic system, and so a full recovery would be expected following delivery. Nevertheless, as with returning to one's original weight and bodily shape, recovery of the lymphoedematous limb may take a bit of time and effort. Increasing levels of exercise and dieting may be necessary.

Genetics, Lymphoedema and Pregnancy

Primary lymphoedema is due to an underlying abnormality in the lymphatics. Although the swelling may not be present until later in life, the abnormality is probably present at birth. It is now recognised that there are some causes of primary lymphoedema that are inherited. Therefore a woman (or man) with primary lymphoedema may have a child with the same condition.

Family History

The best indicator that there is a genetic cause of lymphoedema is the presence of other affected individuals in the family. The commonest way that primary lymphoedema is inherited is from parent to child. This mode of inheritance is called autosomal dominant inheritance. There are two copies of most genes. An autosomal dominant condition is due to an alteration, or 'spelling mistake', in one of the copies. The baby can inherit either the affected gene or the unaffected gene, so the risk to the offspring of inheriting an autosomal dominant condition is 1 in 2, or 50%. Some of the genetic causes of primary lymphoedema are well recognised and are described in more detail below.

Milroy's Disease

Milroy first described a large family with lymphoedema presenting at birth in 1892. It was clear from the family history that this condition was autosomal dominant, and therefore being transmitted from parent to child.Milroy's disease presents predominantly at birth with swelling of the lower limbs, usually the feet. The swelling can increase, or improve, or remain stable. Boys sometimes have extra fluid in the scrotum, but this rarely causes any problems. Milroy's disease is not usually associated with any other abnormalities.Most of the carriers of this condition have some swelling of the lower limbs, but it is recognised that some carriers of the condition are not affected, but may have affected offspring. The lymphoedema in Milroy's disease is due to a lack of lymphatic channels in the lower limbs (hypoplasia or aplasia). The gene for this condition, Vascular Endothelial Growth Factor Receptor 3 (VEGFR3) was identified only recently. This gene is important in the development of the lymphatics of the baby.

Lymphoedema-Distichiasis Syndrome

This condition is another autosomal dominant cause of primary lymphoedema. However, the lymphoedema usually presents in late childhood or puberty.

The age of onset and severity of the swelling varies even within families. The swelling is usually associated with the presence of extra eyelashes on the inner side of the eyelids.

Although the swelling presents later, it is still due to an underlying abnormality of the lymphatic channels. Lymph scans in affected individuals have shown that there are a normal or excess number of lymphatic channels with delayed uptake of lymph in the inguinal lymph nodes, suggesting an abnormality in the function of the lymphatic channels. The mechanism is still unknown. This condition is sometimes associated with other congenital abnormalities. About one third of affected individuals have drooping of the eyelid (ptosis) which occasionally requires surgical correction. There is a slightly increased risk of heart disease at birth (8%). This is not usually severe, but may require surgical repair. A few affected individuals also have a cleft palate (3%). The gene for this condition has been identified; it is a very small gene called FOXC2. It clearly has a role in the development of the lymphatics and eye, but very little is understood about its function.

Risk of Inheriting Lymphoedema

The risk of inheriting lymphoedema for those types where the gene is known and in which a family history exists, is approximately 50%, i.e. 1 in every 2 births. There are, of course, many other causes of primary lymphoedema.Many of these may be genetic but not inherited. Often the underlying cause is not known.

The baby is at an increased risk of inheriting the lymphoedema if any of the following are present:

1. If one parent is affected and has a family history of lymphoedema
2. If the affected parent has distichiasis (extra eyelashes)
3. If the lymphoedema is symmetrical and bilateral.

The baby is at low risk of inheriting lymphoedema if:

1. The affected parent has no family history of lymphoedema
2. There is no distichiasis
3. The swelling is unilateral (including lower limbs)
4. The swelling is not in the lower limbs.

Even if a baby inherits the gene for lymphoedema, it does not mean to say he or she will be as severely affected as the parent. Indeed, the lymphoedema may be very mild despite a severely affected parent.

How Can You Tell If the Baby is Affected

Ultrasound examinations performed during the pregnancy may pick up oedema in a foot or around the back of the neck, both signs that the child may be affected. In the majority of cases, no abnormalities will be observed, and it may only be after birth or sometime later in life that the lymphoedema becomes obvious. In the future it may be possible to test the baby for the offending gene during the pregnancy, but this is not possible at present.

Prevention of Lymphoedema

In the years to come, we hope it will be possible to correct the faulty gene before the baby is born so that the lymphoedema can be reversed. This has been achieved in animals, but not yet in humans. Insertion of the normal gene instead of the faulty one is called gene therapy. It may be possible to do this in adults already affected by lymphoedema. There is hope!

Lipoedema and Pregnancy

Pregnancy may trigger or exacerbate lipoedema and worsen the lymphoedema component of lipoedema. Lipoedema is a condition that results in swelling of the hips, thighs or legs in females. Fluid does contribute to the swelling, but the main component is fat, but in a way different from obesity. In addition to swelling, which gives rise to a 'bottom heavy' or 'chunky, shapeless legs' appearance, symptoms of tissue tenderness and easy bruising are commonplace. Lipoedema tends to develop or deteriorate at times of hormonal change, e.g. puberty, pregnancy and menopause. The condition may not be apparent during the pregnancy because of all the other changes that take place. Following the pregnancy, however, weight loss may prove difficult from the lower half of the body (bottom, thighs and legs). Dieting tends to result in fat loss from face, neck and chest, but not the legs. Treatment is difficult, but a vigorous exercise regimen and healthy eating are recommended. The fluid component of lipoedema appears to be related to poor lymph drainage from the areas of fat deposition. As the fluid increases, so more noticeable oedema develops, particularly in the feet. This is called lipoedemalymphoedema syndrome (lipolymphoedema). Pregnancy may therefore trigger or exacerbate lipoedema.

Conclusions

In summary, in female patients with lymphoedema, pregnancy may create additional concerns with regard to adverse effects on the swelling and the fear of passing on the condition to any offspring. In most cases these concerns are unfounded. Any increase in swelling can usually be managed satisfactorily with the help of a lymphoedema therapist, with a full return to normal once the baby is born. In many individuals the lymphoedema will not change. In the event of a child inheriting lymphoedema, it does not follow that their condition will be the same or worse than that of the parent. The recent upsurge in our knowledge of the genes and proteins involved in lymphatic growth and development means that the possibility of curative or even preventative treatment for primary lymphoedema is greater than ever before.

This article is taken from the Summer 2004 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members

Lymphoedema Support Network

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Pregnancy and Lymphedema

Several months ago one of our readers asked whether pregnancy caused lymphedema to get worse. I reviewed the published literature and, as is too often the case, found very little published information. In addition, what information was available was based on very limited numbers of patients. To gain additional understanding about pregnancy and lymphedema, I created a pregnancy survey for our readers. 13 women have responded to that survey and I am including a summary of their responses and insights.

12 of the 13 women had primary lymphedema. The average age of onset was 10 years of age and the range was from 1 to 16 years of age. 1 patient had breast cancer and a mastectomy and developed lymphedema during her first pregnancy 9 years later.

Of the 12 patients with primary lymphedema, 9 of 12 (75%) had the onset of lymphedema or developed worse lymphedema during their pregnancy. Most of these women found that the lymphedema got worse in the final months of their pregnancy. 2 women reported having persistent lymphedema after delivery.8 women reported second pregnancies and 5 of the 8 (63%) had worsening of their lymphedema and all reported that the lymphedema was worse with the second pregnancy. All 3 women who did not report worsening of their lymphedema had miscarriages that occurred between 3 and 5 months of gestation.4 women reported having third pregnancies and 3 of the 4 had worsening lymphedema with the pregnancy and all reported that the lymphedema became progressively worse with each pregnancy. The remaining woman had a miscarriage.

One woman reported a 4th pregnancy and had worsening lymphedema with the 4th pregnancy but that the lymphedema got better after the delivery of her child.

The one respondent with secondary lymphedema commented that she had been free of lymphedema for 9 years after her mastectomy but developed lymphedema in her hand and forearm during her first pregnancy.

The only women not reporting worsening of their lymphedema during their second and subsequent pregnancies had miscarriages. Miscarriages occur in about 10% of pregnancies so it is notable that so many of the women responding to this survey reported miscarriages. Please keep in mind that a small number of women responded to this survey and any results represent the bias of any small sample. However, it is also possible that the incidence of miscarriages is higher than the expected in women with lymphedema. I will continue to report on additional findings of this survey as we get more information.

Many of the comments made by the women provided interesting insight into the problem of lymphedema during pregnancy so I have included a sample of these comments below.

Comments:

"I am currently in my eighth month of pregnancy and have doubled the size of my left leg. Prior to the pregnancy, I had not swelling in my right leg. Now in my eighth month of pregnancy, my right leg is swelling. I am hoping the swelling in my right leg will go away after the baby is born."

"By 11-12 weeks of pregnancy, my leg was fuller and growing uncomfortable. I was able to continue working full time as a nurse until the 20th week of pregnancy. At that point my leg was heavy and uncomfortable. I was comfortable, however, if I was lying down. During the pregnancy, I gained over 60 lbs., I was very congested in my entire body. I remember having to put my left leg and foot under cold water to reduce the discomfort. I was unable to wear any shoes other than ballet slippers, and could only do minimal walking around the house. After my daughter was born, one to two weeks after her deliver, my leg returned to essentially a pre-pregnancy baseline. My leg improved as I took off the weight gain of fat that naturally occurs with pregnancy. "

"I am currently at the last stage of my third pregnancy, and the swelling is once again more pronounced than in previous months. I tend to be lazier about the stockings this time, so my swelling could probably be better."

"Thank you for posting this survey, I would have enjoyed having some preview of the effects of childbirth on lymphedema. Overall, pregnancy was a temporary setback, which is an important consideration. However, I was still uncertain enough not to attempt my good luck with a second pregnancy. Who knows what the outcome would be, especially after age 35. My personal experience with this condition has led me to believe that insect bites are far worse for my leg. If I get bites on my left leg, my leg gets worse, and doesn't want to return to baseline. It's as if I "loose ground" whenever this happens. The increase with pregnancy, although very substantial, was reversible. It seemed to me to be in indication of lymphatic system overload, rather than tissue scaring or damage. I did notice that as my weight returned to normal, my leg kept improving."

Tony Reid MD Ph.D.

Peninsula Medical, Dr. Reid's Corner

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Pregnancy and Lymphedema: Followup

Last year I presented data on the relationship between pregnancy and lymphedema. Since that time more women have responded to the survey and I presented the update of that survey at the Lymphedema conference held in Dallas, Texas sponsored by Healthtronix.This survey was prompted by several questions that were sent to me asking whether pregnancy worsens lymphedema. For example, a woman had primary lymphedema and was considering an abortion because she was very fearful of her lymphedema getting worse. She already had a bad case of lymphedema and felt that if it got much worse she would no be able to function. There was no published data to help answer these questions and so I posted a survey on our web site to help find some answers to this question.

First, I want to say that the results of the survey are limited by a number of factors. The number of women answering this survey, while growing, is still relatively small. In addition, this is not a random sample of all women with primary lymphedema who have had a pregnancy and effective treatment may change the outcome. This survey only documents the experience of the women who have responded. However, I appreciate the fact that these women have taken the time and effort to answer these questions and I hope that this project will continue to develop and provide additional information that is helpful to women facing this problem.

33 women responded to the survey. Of these, 26 had primary lymphedema and this survey will focus on those 26 responses. Most women with secondary lymphedema have it as a result of treatment for breast cancer. As a result, the majority of these women are past their child bearing years. In addition, the treatment, especially chemotherapy, generally causes infertility. So, most of the women who have lymphedema during their child bearing years have primary lymphedema. I will analyze the results of the women with secondary lymphedema separately. Since there are only a few responses, the data is still limited.

The average age of onset of lymphedema in this group of women with primary lymphedema was 10.7 years but the range of responses was very wide. Some women developed lymphedema at birth while others developed lymphedema in their late teens or twenties.

Of the 26 women with primary lymphedema who responded to this survey, 12 of 26 (46%) reported worsening of lymphedema with the first pregnancy. Of the 12 who had worsening of lymphedema during pregnancy, 7 reported that the lymphedema returned to baseline after delivery so that 5 of 26 (19%) reported persistent lymphedema after pregnancy. However, among the women who improved after delivery, 2 of these women subsequently had worsening of lymphedema within a year. As a result, 7 of 26 (27%) reported lymphedema that was worse following their first pregnancy.

Here are several comments from these women.

"After delivery my leg went back to it's prior size before becoming pregnant. However, after 7 months my leg again became swollen and progressively got worse."

"In my second trimester my ankles began to swell and the doctor assumed it was all normal. After the delivery of my child the swelling in my right leg / ankle went away but the swelling in my left leg continued."

These results suggest that about half of the women with primary lymphedema experienced worsening of lymphedema during their pregnancy. Among the women who reported that their lymphedema worsened with pregnancy, about half of these women reported improvement after delivery of the baby. As a result about 27% (7/26), of the women with primary lymphedema experienced persistent worsening of the lymphedema with pregnancy.

Some of these women had additional pregnancies and I will present the analysis of the results in the subsequent edition of eNews.

Sincerely,

Tony Reid MD, Ph.D

Lymphedema Pregnancy and Followup

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See Also:

Lymphedema People