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28 Cards in this Set
- Front
- Back
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Lymphedema:
-A ..., often inflammatory lymphostatic disease -Abnormal collection of, failure to drain ... rich fluid in the interstitium with resultant edema -Due to defect in ... drainage network -Most commonly in the extremities -Can affect all/any exterior region of the body -Progressive, deforming, debilitating -Physical, functional, and psychological impact |
chronic
protein lymphatic |
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Lymphatic system:
-Retrieves protein filtered from circulatory system by ... and returns to venous system for circulation -Originates as lymph capillaries in spaces between cells -Capillaries join to form larger vessels called ... -Lymphatics are joined by ... that act as filters and empty into right lymphatic or thoracic duct. -Smaller diameter and thinner walls than veins or arteries -Contain ..., like veins, to assist with lymphatic flow -Assisted by skeletal muscle contractions and nearby blood vessel pulsation |
capillaries
LYMPHATICS lymph nodes valves |
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Primary lymphedema:
Due abnormalities in lymphatic system present at ... Not always evident until later in life Three main types: - Congenital lymphedema (... disease) - Lymphedema praecox (... Disease) - Lymphedema ... Associated with other problems/morbidities: -yellow nail syndrome, Turner Syndrome, hemangiomas, neurofibromatosus type 1, Klinefelter syndrome, trisomy 21,13, and 18, distichiasis lymphedema, etc. History of onset helps identify which type it is |
birth
Milroy Meige tarda |
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if you see yellow nail syndrome, check for ...
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primary lymphedema
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Primary lymphedema types:
... -capillaries missing but collecting system present ... - below normal number/diameter of collecting structures ... -valvular insufficiency, reflux |
Aplasia
Hypoplasia Hyperplasia |
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Primary Lymphedema:
Congenital (Milroy Disease) -autosomal dominant familial disorder -evident from birth to age 1 year (usually) -bilateral ..., nonpainful, lower limb edema -associated with cellulitis, prominent ..., hydrocele |
pitting
veins |
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Primary Lymphedema:
Lymphedema ... (... Disease) -most common type of primary lymphedema -... in 70% cases -more common in lower limbs -onset around ...; possible estrogen role - Hypothesis: estrogen causes water and salt retention ,increased blood vessel permeability, and weakened lymphatic pump |
Praecox
Meige unilateral menarche |
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Primary Lymphedema:
Lymphedema Tarda -onset usually after age ... -defect in lymphatic ... |
35
valves |
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Lymphedema ... Syndrome:
Hereditary early and late onset lymphedema with: -... = double row of eyelashes; extra eyelashes -Bilateral lower limb lymphedema, esp. below the knees, onset age 8- 30 years -Enlarged lymphatic vessels in affected areas -Spinal arachnoid cysts, cleft palate, ptosis, short stature, strabismus, microphthalmia, hemangiomas,vertebral abnormalities -Eye irritation Autosomal dominant with variable penetrance Thought to result from mutation in FOXC2 transcription factor |
Distichiasis
Distichiasis |
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Secondary Lymphedema:
... defect in lymphatic system Associated with infection, obesity, neoplasm, trauma, iatrogenic (surgery/radiation therapy) Most common cause worldwide is ... -mosquito borne nematode infection -Wucheria bancrofti -In developing countries Causes ... lymphedema from lymphatic paralysis and thrombosis ASK about travel to/residence in endemic areas |
Acquired
filariasis permanent |
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Secondary Lymphedema:
Most common cause in developed world is ... and its treatment (rule out ...!!!) Most commonly affected area is ... after mastectomy and radical node dissection; also after pelvic/neck node dissection or radiation therapy-causing tissue scarring and fibrosis, varicose vein surgery, lymph node removal Also associated with Hodgkin lymphoma, metastatic prostate cancer, cervical cancer, melanoma. Non cancer associations: Diabetes mellitus, congestive heart failure, portal hypertension, Systemic Lupus Erythematosus and -Trauma: soft tissue injury; DON”T CONFUSE WITH POST TRAUMA EDEMA which should recede quickly -Lymphangitis- red streaks (sometimes), inflamed,enlarged lymph nodes; due to Strep. And/or Staph. -Lyme Disease- Borrelia burgdorferi -Viral infection: herpes simplex, AIDS, vaccinations (rare) -Mycoses: tinea pedis (Trichophyton rubrum) is most common -Dermatitis: acne vulgaris, rosacea -Rheumatoid Arthritis-inflammation spreads to synovia and joint capsule -Hair tourniquet syndrome: lanugo hair winds around digits, genitalia in utero causing lymphatic congestion -Artificial Lymphedema: self inflicted for secondary gain-RARE |
malignancy
cancer axilla |
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Secondary Lymphedema:
Genitalia Lymphedema THINK OF: -... -STDs/Lymphogranuloma venereum (Chlamydia trachomatis) -... MALIGNANCY |
Tuberculosis
HEMATOLOGIC |
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History:
Chronic ... of extremity precedes lymphedema ... precedes proximal involvement Painless (usually) swelling and limb heaviness 80% cases in ... limb Prior: cellulitis, lymphangitis, ulcerations, skin fissuring, verrucous changes, bacterial and fungal infections |
swelling
Distal lower |
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Pain related pearls:
Lymphedema is USUALLY not painful Three Exceptions: 1. INITIAL STAGE: “... pain” -annoying sense of pressure -from accumulated high protein edema fluid -spontaneously subsides when new, pathologic equilibrium is reached 2. EDEMA around ligaments, tendons, in articular capsules and synovial membranes, periosteum -pain from neurogenic inflammation causes increased lymphatic protein, water load, and lymph vessel spasm 3. ... lymphedema -from tumor and/or radiation |
tension
MALIGNANT |
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A positive ... sign (when you try to pull the skin up on the dorsal aspect of a body part and it won’t come up) --> lymphedema (never falsely positive, but negative does not rule out lymphedema)
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stemmer
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Pearls:
-... pressure suprafascial edema= finger pressure always produces indentation -High protein suprafascial edema=indentation only occurs before fibrosclerosis (when lymphedema is ...) -Unilateral and asymmetric lymphedema of lower limb ... be of hepatic, renal, cardiac, endocrine, drug origin. GET TESTS to help with differential or complete diagnosis. -Uncomplicated lymphedema does not have ulcers or tissue necrosis-look for other causes if these are present -Suspect and evaluate for ... in ALL cases of non-congenital lymphedema, esp. if it develops after prior cancer treatment -Once diagnosis is made: do COMPLETE physical exam to detect possible accompanying conditions: lymphangitis, arterial occlusive disease, etc. |
Low
reversible cannot cancer |
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Stages of Lymphedema:
Stage 0 (LATENT) -Time between reduced lymphatic transport capacity and onset of lymphedema -Can last a long time, several years after insult to system Can progress to lymphedema at any time esp. after inciting event (trauma, infection, UV radiation, etc.) ... fibrosclerotic tissue alterations No signs and symptoms |
FOCAL
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Stages of lymphedema:
STAGE ONE - ... -High protein edema; ... fibrosclerotic tissue changes S/S: pitting edema, elevation reduces swelling, possible “pain of congestion/tension pain” |
REVERSIBLE
FOCAL |
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Stages of lymphedema:
STAGE 2-SPONTANEOUSLY ... -Extensive, ... fibrosclerosis -Proliferation of adipose tissue -Brawny, hard swelling that does not improve with elevation Mild to moderate decline in function |
IRREVERSIBLE
diffuse |
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Stages of lymphedema:
STAGE 3-... -Extensive fibrosclerosis and proliferation of adipose tissue Moderate to severely decreased function |
ELEPHANTIASIS
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Lab studies:
Not to ... lymphedema TO IDENTIFY UNDERLYING CAUSE OR CONCURRENT ISSUES If suspect neoplasm, check ... markers If infection suspected, check ... with differential |
diagnose
tumor CBC |
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imaging studies:
Not needed to make diagnosis Can confirm diagnosis, determine extent of involvement, or help decide/revise treatment course ... allows detailed visualization of lymphatic channels with minimal risk |
LYMPHOSCINTIGRAPHY
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Other tests:
BIOPSY -if diagnosis is elusive -if suspect other associated conditions -if chronic ... are present or recur AVOID removing ... -can cause or worsen lymphedema Do PUNCH/PUNCTURE Biopsy Histology: hyperkeratosis with areas of parakeratosis, acanthosis, diffuse dermal edema, dilated lymphatic spaces; if chronic, marked fibrosis, scattered foci of inflammatory infiltrate |
ulcers
lymph nodes |
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Complications of lymphedema:
Fissuring, ulcerations, recurrent cellulitis Self-inoculation from mouth, ear, nose, anal area, going barefoot Concurrent malignancy -... (Stewart-Treves Syndrome): most common after radical mastectomy and node dissection; malignant skin tumor associated with lymphedema;penetrates subcutaneous tissue and fascia. Suspect if ... -like spot with lymphedema. Requires histologic diagnosis Squamous cell carcinoma, B-cell lymphoma, malignant fibrous histiocytoma |
Lymphangiosarcoma
hematoma |
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complications of lymphedema:
Chronic inflammation: -Erysipelas: superficial cellulitis -caused by Group .... -chills, fever, malaise, nausea, headache, rosy red painful skin, possible blisters, bad taste in mouth -worsens lymphedema -can become chronic -after infection recedes, sterile inflammation continues as a result of cell death - do not mis-diagnose as thrombophlebitis (much less common) |
A Strep
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complications of lymphedema:
Cellulitis: -acute, diffuse, spreading, edematous, suppurative inflammation of deep subcutaneous tissue (and sometimes muscles) with occasional abscess. -Caused by Group ... and ... Impaired mobility and ADLs, socialization, medical care access, ability to work/attend school |
A Strep.
S. aureus |
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Complex Decongestive Therapy (CDT):
Effective for decongestion Decreases incidence of infection and erysipelas Patient/family compliance ESSENTIAL for success Therapist skill MAKES A DIFFERENCE CONTRAINDICATED IF: -... edema -... -unless adequate current treatment ongoing and CDT is minimized in the area of the tumor |
cardiac
malignancy |
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Medical treatment:
-If secondary lymphedema, find and treat underlying cause and address associated conditions -Treat infections ... than usual and with drugs that hit skin and soft tissue well -Long term antibiotic therapy if cellulitis recurs. Penicillins and cephalosporins work well. -Penicillin prophylaxis for dental extractions/infections -If filariasis, give albendazole and diethylcarbamazine -If obesity is associated, recommend weight loss -Topical emollients and keratolytics ( urea-Carmol,Ureacin,etc) , ammonium lactate( Lac-Hydrin,etc.) -Limb protection and elevation -...: not effective for treating lymphedema-they increase plasma protein concentration secondary t increased water excretion and they slow lymph transport |
longer
Diuretics |
