Elephantiasis Nostras Verrucosa (ENV): A Complication of Congestive Heart Failure and Obesity

Abstract

Congestive heart failure (CHF) and obesity are common medical conditions that have many complications and an increasing incidence in the United States. Presented here is a case of a disfiguring skin condition that visually highlights the dermatologic consequences of poorly controlled CHF and obesity. This condition will probably become more common as CHF and obesity increase in the US. A 48-year-old man presented to our clinic complaining of 7 months of worsening, bilateral leg swelling with painful, oozing "water sores." He also described worsening dyspnea on exertion and 3-pillow orthopnea. His medical history was significant for poorly controlled congestive heart failure (CHF); obesity (body mass index, 43 kg/m 2 ); atrial fibrillation; and diabetes mellitus. He had no significant travel history or family history.During physical examination vital signs showed mild hypoxia, tachypnea, and a fever of 101.6°F. Jugular venous distension, bibasilar crackles, and an irregular heart rhythm were present. The lower legs revealed significant pitting edema with woody, indurated skin that had a circumferential confluence of weeping plaques with a pebbled, verrucous appearance (see Figures 1, 2, and 3).Laboratory evaluation revealed normal complete blood count, cardiac enzymes, metabolic panel, and thyroid studies. Abnormal laboratory values included a C-reactive protein level of 4.1 mg/dL (normal, 0 to 1.0) and brain naturetic peptide level of 342 pg/mL (normal, 0 to 100). Chest radiography showed diffuse pulmonary infiltrates and electrocardiogram showed atrial fibrillation. The patient was admitted for an acute CHF exacerbation and presumed cellulitis. A wound culture grew multiple organisms (Staphylococcus aureus, Serratia marcescens, Citrobacter koseri, Acinetobacter lwoffii) but blood and fungal cultures were negative. A skin punch biopsy was consistent with stasis dermatitis and, based on clinical examination, the patient was diagnosed with elephantiasis nostras verrucosa (ENV) with overlying acute lymphangitis. A conservative therapy was adopted to control his ENV, specifically antibiotics to treat the acute in-

Elephantasis Nostras Verrucosa and Psoriasis

“…Triggering factors of ENV include heartworm infections, tumors, traumas, radiation therapy, previous surgery, congestive heart failure, obesity, hypothyroidism, chronic venous insufficiency, and scleroderma. 1,5,9 In our patient's case, we identified chronic venous insufficiency, obesity, and congestive heart failure as causative factors for ENV. We think that psoriasis may contribute to worsening of papillomatous and hyperkeratotic lesions, as in the case reported by Polat and Sereflican.…”

“…5 Histological features of ENV are hyperkeratosis, papillomatosis, verrucous hyperplasia, and dermal fibrosis with proliferation of adipocytes and fibroblasts 6 .…”

Elephantiasis nostras verrucosa secondary to congestive cardiac failure

“…Aetiologies for ENV include CCF,1 radiation, pretibial myxoedema, portal hypertension, obesity, tumour or surgical damage to the lymphatic system. Although the exact pathogenesis of ENV is unclear, a major contributing factor is a vicious cycle of chronic lymphoedema and repeated infections 2.…”

A Case of Progressive Elephantiasis Nostras Verrucosa

“…It has been postulated that the protein-rich lymphatic fluid present in the interstitium decreases the local immune response and thus predisposes the patient to skin infections that further provoke the onset of subcutaneous fibrosis (2). Magnetic resonance imaging (T1) reveals a characteristic complex honeycomb structure containing thickened subcutaneous tissue (Picture 4).…”