Dermatology Online Journal

Letter: Elephantiasis nostras verrucosa on the abdomen of a Turkish female patient caused by morbid obesity
D Buyuktas¹, E Arslan², O Celik¹, E Tasan¹, C Demirkesen³, S Gundogdu¹
Dermatology Online Journal 16 (8): 14

1. Division of Endocrinology and Metabolism, Department of Internal Medicine, Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey. sadigundogdu@gmail.com
2. Department of Nuclear Medicine, Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey
3. Department of Pathology, Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey

---

Abstract

Elephantiasis Nostras Verrucosa is a rare disorder of an extremity or a body region, which is associated with chronic lymphedema. There are 7 reported cases of abdominal elephantiasis in the medical literature. Here we report a morbidly obese female patient with elephantiasis nostras verrucosa on the abdominal wall.

---

Introduction

Elephantiasis Nostras Verrucosa (ENV) is a rare, chronic, deformative, dermatological disorder that is characterized by dermal fibrosis and hyperkeratotic, verrucous, and papillomatous lesions. Chronic non-filarial lymphatic obstruction plays an important role in its pathogenesis [1]. Although it can affect any body region, it usually involves the lower extremities and the external genitalia. Elephantiasis Nostras Verrucosa involving the abdominal wall is uncommon. This report is about a morbidly obese woman who had elephantiasis nostras verrucosa lesions on the abdominal wall.

Case report

Figure 1	Figure 2
Figure 1. Elephantiasis nostras verrucosa lesions of the abdominal wall of the morbid obese female patient Figure 2. Histologic examination of the abdominal skin lesions showed dermal fibrosis, acanthosis of the epidermis with vessel proliferation.

A 33-year-old woman with morbid obesity who suffered from progressive deformative edema and fibrosis of the abdominal wall was referred to our department. She reported one episode of cellulitis of her left leg 5 years prior to presentation; she had been suffering from abdominal lesions for 4 years. Her medical history was negative for filariasis, congestive heart failure, liver or renal disease, surgery, radiation therapy, and neoplastic disorders. She had no family history of familial lymphedema. The abdominal wall and legs were edematous. The body mass index was 72 kg/m². She had cobblestone-like, thickened, hyperpigmented and fissured plaques on the abdomen (Figure 1). A biopsy was performed from the abdominal skin. Histopathological examination showed dermal fibrosis, acanthosis of the epidermis, and vessel proliferation, which are characteristic of ENV (Figure 2).

She was evaluated for conditions other than obesity, which can lead to ENV. There were no abdominal masses (that could cause lymphatic obstruction) noted with abdominal ultrasonography. There was no sign of hepatic, renal, or thyroid disease by laboratory analysis. She had no signs of cardiac failure clinically or by echocardiography.

Treatment for obesity was initiated. Surgical treatment could not be performed considering the high risk of morbidity and mortality caused by her morbid obesity and obstructive sleep apnea.

Discussion

Elephantiasis Nostras Verrucosa is an uncommon, but deformative and progressive cutaneous disease caused by chronic lymphedema and recurrent streptococcal infections. Chronic lymphedema can occur for many reasons including obesity, infection, trauma, surgery, portal hypertension, tumor obstruction, radiation therapy, congestive heart failure, thyroid disease, and Kaposi sarcoma [1, 2, 3].

It usually affects the lower extremities and the external genitalia [4]. There are only 7 case reports in the medical literature of ENV involving the abdominal wall [3-9]. The histopathology reveals dermal fibrosis, acanthosis, hyperkeratosis of the epidermis, and multiple dilated lymphatic capillaries. Pretibial myxedema, stasis dermatitis, and filariasis must be considered in the differential diagnosis. The treatment of this chronic and deformative disease includes antibiotics, diuretics, compression stockings, topical keratolytics, pneumatic compression devices, mechanical massages, oral retinoids, elevation of the affected limb, and surgical measures. Surgical treatment involves partial lipectomy, debridement of the lesions, and lymphovenous or lymphatic anastomosis [10].

Morbid obesity was considered as a predisposing factor for ENV in our case. The patient had co-morbid factors including morbid obesity and obstructive sleep apnea. Therefore, she was not a candidate for surgical treatment. Anti-obesity treatment and local keratolytic treatment for the lesions were the treatments initiated.

In conclusion: early diagnosis is important for the treatment and prevention of complications. The initial stages of this condition can be treated more satisfactorily.

References

1. Schissel DJ, Hivnor C, Elston DM. Elephantiasis nostras verrucosa. Cutis 1998 Aug; 62 (2) : 77-80. [PubMed]

2. Ukinc K, Bayraktar M, Gedik A. Hypothyroid Graves’ disease complicated with elephantiasis nostras verrucosa (ENV): a case report and review of the literature. Endocrine 2009 Aug ; 36 (1) :6-9 . [PubMed]

3. Sathyakumar S, Suh JS, Sharp VL, Polsky B. Images in HIV/AIDS. Elephantiasis nostras verrucosa secondary to Kaposi sarcoma:a rare case.AIDS Read 2008 Feb;18 (2):81-82 . [PubMed]

4. Hanna D, Cloutier R, Lapointe R, Desgagne A. Abdominal elephantiasis : a case report. J Cutan Med Surg. 2004 Jul-Aug ; 8 (4) :229-232 . [PubMed]

5. Chernosky ME ,Derbes VJ. Elephantiasis nostras of the abdominal wall. Arch Dermatol. 1966 Dec ;94 (6) :757-762 . [PubMed]

6. Rudolph RI, Gross PR. Elephantiasis nostras verrucosa of the panniculus . Arch Dermatol 1973 Dec; 108 (6) :832-834. [PubMed]

7. Boyd J, Sloan S, Meffert J. Elephantiasis nostrum verrucosa of the abdomen: clinical results with tazarotene. J Drugs Dermatol. 2004 Jul-Aug; 3 (4): 446-448. [PubMed]

8. Shaposhnikov AV, Matveev NV. Elephantiasis of the anterior abdominal wall. Klin Khir. 1985;7:76-77. [PubMed]

9. Sarma PS, Ghorpade A. Elephantiasis nostras verrucosa on the legs and abdomen with morbid obesity in an Indian lady. Dermatol Online J. 2008 Dec 15 ;14 (12):20. [PubMed]

10. Iwao F, Sato-Matsumura KC, Sawamura D, Shimizu H. Elephantiasis nostras verrucosa successfully treated by surgical debridement. Dermatol Surg. 2004 Jun ;30(6):939-941. [PubMed]

© 2010 Dermatology Online Journal