Bilateral lower extremity inflammatory lymphedema (BLEIL) is a distinct clinical entity characterized by acute

lymphedema Lymphedema, also known as lymphoedema and lymphatic edema, is a condition of localized swelling caused by a compromised lymphatic system. The lymphatic system functions as a critical portion of the body's immune system and returns interstitial fl ...

in both

ankles The ankle, or the talocrural region, or the jumping bone (informal) is the area where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular join ...

and lower legs after being exposed to prolonged standing, such as during military

basic training Military recruit training, commonly known as basic training or boot camp, refers to the initial instruction of new military personnel. It is a physically and psychologically intensive process, which resocializes its subjects for the unique deman ...

Presentation

Patients present with an acute onset of swelling, pain, erythema, prominent tenderness, warmness and limited range of motion in both ankles. Lower legs and heels may also be involved, however the distal parts of feet and toes are usually spared. Patients may also experience high-graded fever, pitting edema and hypotension. The clinical presentation usually resembles cellulitis, however bilateral involvement is a differentiating feature.

Cause

The pathophysiology is not yet well understood. Leukocytoclastic

vasculitis Vasculitis is a group of disorders that destroy blood vessels by inflammation. Both arteries and veins are affected. Lymphangitis (inflammation of lymphatic vessels) is sometimes considered a type of vasculitis. Vasculitis is primarily caused b ...

is proposed to be the underlying cause resulting in reactive lymphedema. Prolonged standing with full knee extension and minimal movement for a prolonged period of time is postulated to induce a temporary failure in pumping the venous and lymphatic systems in the calf region leading to acute gravity-dependent

venous congestion Venostasis, or venous stasis, is a condition of slow blood flow in the veins, usually of the legs. Presentation Complications Potential complications of venous stasis are: * Venous ulcers * Blood clot formation in veins (venous thrombosis), that ...

, deposition of

immune complex An immune complex, sometimes called an antigen-antibody complex or antigen-bound antibody, is a molecule formed from the binding of multiple antigens to antibodies. The bound antigen and antibody act as a unitary object, effectively an antigen of ...

es, thus leading to a deep dermal inflammatory vasculitis.

Diagnosis

Marked elevation of inflammatory markers is seen, including

white blood cells White blood cells, also called leukocytes or leucocytes, are the cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders. All white blood cells are produced and derived from mult ...

erythrocyte sedimentation rate The erythrocyte sedimentation rate (ESR or sed rate) is the rate at which red blood cells in anticoagulated whole blood descend in a standardized tube over a period of one hour. It is a common hematology test, and is a non-specific measure of ...

and C-reactive protein. Other laboratory tests are usually within the reference range. Imaging modalities, such as MRI, show extensive soft tissue edema, especially around medial and lateral

malleoli A malleolus is the bony prominence on each side of the human ankle. Each leg is supported by two bones, the tibia on the inner side (medial) of the leg and the fibula on the outer side (lateral) of the leg. The medial malleolus is the promine ...

Treatment

Rest and leg elevation are the mainstay of the treatment bringing rapid relief.

Compression stockings Compression stockings (Flight Socks, Support Bandage) are a specialized hosiery designed to help prevent the occurrence of, and guard against further progression of, venous disorders such as edema, phlebitis and thrombosis. Compression stockings ...

are also proposed to reduce the stasis and fasten the recovery, however there is no clinical study to prove their effectiveness in BLEIL.

Epidemiology

Bilateral lower extremity inflammatory lymphedema is described in otherwise healthy young adults undergoing recruit training where they are exposed to prolonged standing. The condition manifests during the first few days of starting the training.

History

The first cases reported in the literature are described in Air Force basic trainees in August 2011 at Lackland Air Force Base,

Texas Texas (, ; Spanish language, Spanish: ''Texas'', ''Tejas'') is a state in the South Central United States, South Central region of the United States. At 268,596 square miles (695,662 km2), and with more than 29.1 million residents in 2 ...

References

{{reflist Lymphatic vessel diseases Diseases of veins, lymphatic vessels and lymph nodes Foot diseases Military medicine