A 40-year-old woman has slowly progressive swelling of the left lower limb since adolescence. On examination the swelling is initially soft and pits on pressure, but the skin later becomes thickened and non-pitting. The skin folds at the base of the second toe cannot be picked up and thicken when pinched. Which investigation is the accepted reference standard to confirm her diagnosis?

• A Duplex ultrasonography of the limb veins
• B Isotope lymphoscintigraphy ✓
• C CT venography
• D Serum albumin estimation

Explanation

The inability to pinch a skin fold at the base of the second toe, the Stemmer sign, is characteristic of lymphoedema, which progresses from early pitting oedema to non-pitting fibrotic thickening. Isotope lymphoscintigraphy is the reference standard diagnostic test, showing delayed or absent lymphatic transit and dermal backflow. Venous duplex excludes venous insufficiency but cannot confirm lymphatic failure, and hypoalbuminaemia causes generalised pitting oedema without a Stemmer sign. Early compression therapy is the mainstay of management regardless of whether the lymphoedema is primary or secondary.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

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