Elephantiasis Nostras Verrucosa

A 60-year-old man was hospitalized with fever and hypotension secondary to recurrent cellulitis of the left leg. He had a history of polysubstance abuse and hepatitis C. Elephantiasis nostras verrucosa was diagnosed based on bilateral nonpitting edema and hyperkeratotic verrucous lesions in the pretibial area. The patient's erythrocyte sedimentation rate and white blood cell count showed evidence of infection; osteomyelitis of the left fifth metatarsal head was suspected.

The patient was treated with intravenous ampicillin/ sulbactam, antifungal cream application for 4 weeks, and leg elevation. Within 3 weeks, his temperature had normalized and the lymphedema and cellulitis had decreased. He was discharged in good condition after 6 weeks.

Recurrent cellulitis can lead to lymphangitis and subsequent lymphedema. Persistent lymphedema predisposes persons to further infection, which causes chronic skin changes and ensuing epidermal hyperplasia.¹ Elephantiasis nostras verrucosa may also occur as a sequela of chronic venous or lymphatic stasis.² It should be differentiated from lymphangioma; acquired lymphangiectasia; and lymphedema secondary to filariasis, syphilis, or tuberculous lymphangitis.³

Any area of the body can be affected. The skin disfiguration is largely irreversible; the condition has been described as a permanent hypertrophic fibrosis.²

Treatment consists of antibiotics, elevation of the affected limb, and the use of compressive stockings. Antifungal agents may be prescribed if an associated dermatophytosis is suspected.^2,4,5 Recurrences are managed similarly; however, a persistent focus of infection should be sought.^2,4 Long-term therapy with erythromycin or penicillin may also be considered.^2,3 Plastic surgery is an option for patients with solid edema that is unresponsive to medical management.^3,4 *