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Why does this man have backache and swollen ankles?

This patient was more concerned with his backache than swollen ankles. Dr Oliver Starr reveals how they were connected

 

The patient

This man had been having lower back pain for about six months and was seeing a physiotherapist who had told him to ‘see your GP about getting a scan'. He said his lower legs had lately been a bit swollen. As he pulled up his trousers to show me, I found he had pitting oedema to his knees, which had come on over a few weeks. He had also had some problems maintaining an erection, which he put down to the emotional impact of starting IVF with his fiancée. He was on no regular medication.

He was pretty keen on an MRI scan of his lower back, as he'd had right-sided lumbago for a few months that hadn't responded to analgesia or physiotherapy. I explained to him this wouldn't be appropriate at this point, suggesting we start investigating his problems with a blood test.

First instinct

Examining him, his abdomen was soft and had no masses. Cardiorespiratory examination was normal and there was no inguinal lymphadenopathy.

At his age, I thought the most likely diagnosis was on a renal pathology – and this suspicion was strengthened when his U&Es came back showing a creatinine of 142, a little high for a 42-year-old.

Differential diagnoses

• Nephropathy

• Venous insufficiency

• Congestive heart failure

• Pelvic venous obstruction.

I discounted my main differential – intrinsic renal disease – when a dipstick was clear of protein and the lab result showed no suggestion of microalbuminuria.

He was a little young to have venous insufficiency and there were certainly no varicose veins. His heart sounds were normal, jugular venous pressure was not raised and B-type natriuretic peptide (BNP) was normal, which ruled out heart failure – although even if it had been raised, it's worth noting that BNP can be pushed up in renal failure in the absence of left ventricular failure.

There were no objective signs of pelvic venous obstruction, although this was mainly limited to my examination of inguinal nodes.

Getting on the right track

Events overtook us when he came back less than a week later with a grossly swollen right leg, was admitted to hospital with a femoral DVT and was given warfarin. It was there that a small lump on the superior pole of the right testis was found and confirmed on ultrasound. The following abdominal and pelvic CT showed widespread retroperitoneal lymphadenopathy. The lymph glands were compressing a ureter, hence the rise in creatinine. They were also responsible for his lower back pain, which explained why physiotherapy hadn't helped.

He was transferred to a tertiary centre where the first cycle of chemotherapy for the testicular tumour was followed by an improvement in leg swelling.

How will this change my practice? When a man presents with swollen legs, I'll now examine his testicles.

Dr Oliver Starr is a GP in Stevenage, Hertfordshire

Why does this man have backache and swollen ankles?

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Readers' comments (6)

  • really interesting

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  • Interesting case:
    Others associations I had come across were:
    Meralgia paraesthetica=Pelvic mass
    Unilateral Varicocele - Renal Ca

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  • It would change my practice as well This highlights the danger of not falling for carrying out tests insisted by preempted patients.Sometimes it can be dangerous without one's own thorough assessment.
    It also highlights the need to view what seems a routine presentation of a back pain more panoramically looking for differentials as you have right done .
    Can you imagine what would have happened to you if you had missed such tell-tail signs of a distal oedema.
    Personally , i tend to investigate all distal oedema for a pelvic pathology Taking further all suspected and diagnosed DVT in a patient with little risk factors for a pelvic pathology.

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  • Thank you for a very interesting case presentation. Have learnt some key points!

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  • 20 yrs ago neighbour c/o swollen ankles (female aged 63). Her GP dismissed it as due to hot weather, 6 months later she died of ovarian cancer. Like SO I've treated distal oedema with suspicion ever since

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  • very much informative , specially in cases of bilateral swollen legs in male patients.

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