When lymphedema becomes elephantiasis: a multidisciplinary challenge in a patient with severe obesity and cardiopulmonary comorbidities

Lymphedema is a progressive condition that can reach an extreme, debilitating stage known as elephantiasis. This case presents a 57-year-old man with stage III by International Society of Lymphology (ISL) lower limb primary lymphedema diagnosed by a lymphoscintigraphy, morbid obesity (BMI >65), obesity hypoventilation syndrome, chronic pulmonary heart disease, and story of prior pulmonary embolism. At admission, high-resolution ultrasound revealed severe subcutaneous thickening, with maximum values exceeding 11 cm. A multidisciplinary inpatient approach was implemented involving vascular surgeons, internists, cardiologist, urologist, pneumologist, dietitians, physiotherapists, and specialized nursing care. Only through the collaboration among all these professional figures it was possible to manage such a complex case. Treatment included high-pressure multilayer compressive bandaging and a Very-Low-Calorie Ketogenic Diet (VLCKD). This led to a significant reduction in subcutaneous thickness (up to 80% in some sites). During three weeks of hospitalization the weight loss was only 7 kg, little but nevertheless relevant, probably due to the total immobility and the poor compliance of the patient. The case underscores the importance of coordinated nutritional, vascular, and medical care in managing complex, end-stage lymphedema.