case_images: PMC10729832_01
case_images: Left leg pitting edema, with hyperpigmented skin and flexion-contraction of the knee.
case_images: IMCRJ-16-847-g0001.jpg
case_images: PMC10729832_01_IMCRJ-16-847-g0001.jpg
case_images: f0001
case_images: Vital signs at the emergency triage were:- blood pressure = 79/36mmHg; pulse rate = 112; respiratory rate = 22 Saturation; oxygen - 97% on atmospheric air and he had a pale conjunctiva; left leg pitting edema with shiny appearance as shown in Figure 1; tender to palpation; restriction of extension of the knee joint; shortness of breath; and dry cough of one-week duration.
case_images: PMC10729832_02
case_images: Showing gum hypertrophy.
case_images: IMCRJ-16-847-g0002.jpg
case_images: PMC10729832_02_IMCRJ-16-847-g0002.jpg
case_images: f0002
case_images: Vital signs at the ED triage were blood pressure, -98/64 mmHg; pulse rate, - 110; respiratory rate, - 24; body temperature - 37 C and saturation of oxygen on atmospheric air, 95% and he also had pale conjunctiva; Hypertrophied gum (see Figure 2, right); right leg edema with shiny skin (see Figure 3, left); and tenderness to palpation with a leg-leg discrepancy of 2 cm.
case_images: Shiny, edematous and hyperpigmented right leg.
case_images: IMCRJ-16-847-g0003.jpg
case_images: PMC10729832_02_IMCRJ-16-847-g0003.jpg
case_images: f0003
case_images: Vital signs at the ED triage were blood pressure, -98/64 mmHg; pulse rate, - 110; respiratory rate, - 24; body temperature - 37 C and saturation of oxygen on atmospheric air, 95% and he also had pale conjunctiva; Hypertrophied gum (see Figure 2, right); right leg edema with shiny skin (see Figure 3, left); and tenderness to palpation with a leg-leg discrepancy of 2 cm.
case_images: PMC10729832_03
case_images: Diffuse left leg and thigh swelling with semi flexed position.
case_images: IMCRJ-16-847-g0004.jpg
case_images: PMC10729832_03_IMCRJ-16-847-g0004.jpg
case_images: f0004
case_images: In the ED, the vital signs were stable and he had a pale conjunctiva as well as palmar pallor and left leg and thigh has pitting edema, tender to palpation and there is joint stiffness at the knee joint which restricts full extension of the knee joint (as shown in Figure 4) and hypertrophied lower gingiva (see Figure 5).
case_images: Gum hypertrophy and mucosal hyperpigmentation.
case_images: IMCRJ-16-847-g0005.jpg
case_images: PMC10729832_03_IMCRJ-16-847-g0005.jpg
case_images: f0005
case_images: In the ED, the vital signs were stable and he had a pale conjunctiva as well as palmar pallor and left leg and thigh has pitting edema, tender to palpation and there is joint stiffness at the knee joint which restricts full extension of the knee joint (as shown in Figure 4) and hypertrophied lower gingiva (see Figure 5).
case_images: PMC10729832_04
case_images: Right leg shiny diffuse swelling with a right leg flexion at knee joint and visible leg-leg discrepancy.
case_images: IMCRJ-16-847-g0006.jpg
case_images: PMC10729832_04_IMCRJ-16-847-g0006.jpg
case_images: f0006
case_images: Circumferential leg-leg discrepancy of 10 cm on the calf and 4 cm in the thigh area (see Figure 6).
case_images: PMC10729832_05
case_images: (A) Severe gum hypertrophy with erythema and ulceration. (B) Pale tongue with overlying erythematous patch and perioral hyperpigmentation in a young male patient prisoned for 15 months.
case_images: IMCRJ-16-847-g0007.jpg
case_images: PMC10729832_05_IMCRJ-16-847-g0007.jpg
case_images: f0007
case_images: Both the upper and lower gingiva were severely hypertrophied, with ecchymosis and ulceration over the left upper inner part of the gum (as shown in Figure 7A) and a pale tongue with erythematous patch and perioral hyperpigmentation (as shown in Figure 7B).
case_images: Hyperpigmented, trace pedal edema of both right and left leg.
case_images: IMCRJ-16-847-g0008.jpg
case_images: PMC10729832_05_IMCRJ-16-847-g0008.jpg
case_images: f0008
case_images: The right leg was tender on palpation, but no leg-leg discrepancy and he had a trace pedal edema (as seen in Figure 8).
case_images: Hyperpigmented (macule-patchy) skin lesion over the dorsum of the left hand.
case_images: IMCRJ-16-847-g0009.jpg
case_images: PMC10729832_05_IMCRJ-16-847-g0009.jpg
case_images: f0009
case_images: He also had palmar pallor, perifollicular hyperpigmentation and macule to patchy hyperpigmentation over the dorsum of the hand (as seen in Figure 9).
case_images: (A) The same patient on Figure 7A, 11 days after ascorbic acid initiation the severe gum hypertrophy regressed significantly. (B) The same patient on Figure 9, 11 days after ascorbic acid initiation, the hyperpigmentation over the dorsum of the hand is fully subsided.
case_images: IMCRJ-16-847-g0010.jpg
case_images: PMC10729832_05_IMCRJ-16-847-g0010.jpg
case_images: f0010
case_images: Subsequently, he was transferred to the medical ward and stayed for sixteen days as in patient, and on the eleventh day of admission the gum hypertrophy decreased significantly (see Figure 10A) and the patchy hyperpigmentation over the dorsum of the hand is gone (see Figure 10B).
case_images: PMC10729832_06
case_images: Right leg swelling with shiny appearance, darkening and flexion contracture at the knee joint.
case_images: IMCRJ-16-847-g0011.jpg
case_images: PMC10729832_06_IMCRJ-16-847-g0011.jpg
case_images: f0011
case_images: Vital signs were stable in the medical OPD and he had pink conjunctiva, minimal gum hypertrophy and right leg is having a pitting edema with a shiny appearance (as shown in Figure 11) and tenderness on palpation.
case_images: PMC10729832_07
case_images: PMC10729832_08
case_images: Ecchymotic gingiva.
case_images: IMCRJ-16-847-g0012.jpg
case_images: PMC10729832_08_IMCRJ-16-847-g0012.jpg
case_images: f0012
case_images: Figure 12) over the upper and lower gingiva, but no gum hypertrophy. Furthermore, the patient had a Grade II bilateral pitting edema (as seen in Figure 13B) and hyperpigmented dorsal surface of the ankle of both extremities with contracted and a semi flexed left knee (as seen in Figure 13A) and also the left knee could not be extended fully, either actively or passively (as seen in Figure 14).
case_images: (A) Hyperpigmented dorsal surface of the ankle of both extremities with contracted and a semi flexed left knee at admission. (B) Bilateral pitting edema at admission.
case_images: IMCRJ-16-847-g0013.jpg
case_images: PMC10729832_08_IMCRJ-16-847-g0013.jpg
case_images: f0013
case_images: Figure 12) over the upper and lower gingiva, but no gum hypertrophy. Furthermore, the patient had a Grade II bilateral pitting edema (as seen in Figure 13B) and hyperpigmented dorsal surface of the ankle of both extremities with contracted and a semi flexed left knee (as seen in Figure 13A) and also the left knee could not be extended fully, either actively or passively (as seen in Figure 14).
case_images: Left knee during active extension, that failed to extend fully and stayed in a semi extended position at admission.
case_images: IMCRJ-16-847-g0014.jpg
case_images: PMC10729832_08_IMCRJ-16-847-g0014.jpg
case_images: f0014
case_images: Figure 12) over the upper and lower gingiva, but no gum hypertrophy. Furthermore, the patient had a Grade II bilateral pitting edema (as seen in Figure 13B) and hyperpigmented dorsal surface of the ankle of both extremities with contracted and a semi flexed left knee (as seen in Figure 13A) and also the left knee could not be extended fully, either actively or passively (as seen in Figure 14).
case_images: The same patient on Figure 14, fully extended left knee on active extension after 14 days of in-patient management with ascorbic acid.
case_images: IMCRJ-16-847-g0015.jpg
case_images: PMC10729832_08_IMCRJ-16-847-g0015.jpg
case_images: f0015
case_images: His management course was as follows: he was started on ascorbic acid 1000 mg with 300 mL of water on the day of the admission at the ED with Iron sulphate 325 mg (65 mg elemental iron), folic acid 5 mg to be taken once daily, Cyanocobalamin 1mg IM daily and after five days of his admission to the medical ward and after collecting the investigations he was started on Anti-TB RHZE 03 tabs to be taken daily with 50 mg of pyridoxine daily and on the fourteenth day of stay as inpatient management he can extend his left knee completely without any restriction (see Figure 15) and the bilateral pitting edema has subsided (see Figure 16).
case_images: PMC10729832_09