Swollen red left foot, EM or no? PCP thinks it could be EM but not sure. Don’t know where to go from here?

General
#1

Hi, I am a 34 year old female, I live in Nevada USA. I hoping some of you can help me out. My PCP thinks I may have EM. I provided her with a list of possible vascular related diseases that I thought my symptoms seemed similar to and she thinks EM may fit my symptoms best.

Symptoms: My symptoms are as follows: my left foot has been mildly swollen (edema) for a few months now. The swelling is primarily located in the toe area and just below the toes. The swelling often increases and is accompanied by redness and a hot feeling, mostly at night or while I am sleeping or after I get out the shower or after a lot of excercise. I have no pain. Just an uncomfortable, tight feeling from the swelling. The swelling is present consistently but gets worse after the stated events. During the day and during my visits to the various doctors it doesn’t hardly appear swollen and there is no redness. Sometimes after I shower both of my feet not just my left foot get extremely hot, itchy and red. So much so that I immediately need to lay horizontal with a fan on. Otherwise my right foot shows no other symptoms. It is just my left foot. When I sleep I have to leave my left foot uncovered it gets very hot and swollen at night. I have no other redness or swelling elsewhere in my body. PICTURES OF MY SYMPTOMS

Prior injury: My left foot has had a previous injury to my large toenail bed. I have had an ingrown toenail removed there about 6 years ago and have repeated subungual hematoma’s (bleeding under the toenail) from hiking over the years. My most recent toenail injury was maybe a year ago. My toenail has since grown back thickened and deformed.

Diagnosis: When I first discussed my foot issues with my PCP in early January 2020, she assumed cellulitis infection due to my history of toenail injuries. I was placed on Augmentin antibiotics for 7 days. There was no improvement. She then had an ultrasound of my leg ordered to check for veinous issues like blood clots. The results were normal. She then ordered bloodwork rheumatoid related bloodwork such as CCP, CRP, Sed Rate, and Rheumatoid factors, and then also had CBC diff bloodwork completed. All results were normal. No sign of infection or inflammation. I also saw a podiatrist who ruled out fungal infections. I then asked her if my symptoms could be one of the following diseases based on some internet research I completed: lymphedema, May Thurner syndrome, CRPS, DVT, or EM. She thought EM seemed the most likely but the etiology is unclear. She then prescribed lidocaine patches (which my insurance denied) and basically that’s been it so far. Not sure where to go from here.

I have been reading the posts on here which are very helpful. I am not sure if my symptoms seem to fit exactly with EM though. Mainly the constant swelling and only having symptoms in one foot as opposed to several parts of the body as others have mentioned. Are there other specialists or types of doctors I should try to get a second opinion from? I am not sure where to go from here. Thanks

#2

If it is EM I wouldn’t push too much for the patches, in my own experience lidocaine patches have done nothing for me but then again everyone is different. It being in only one foot as well is very strange but that doesn’t mean it isn’t impossible.

To me it looks like you could be having a possible allergic reaction, have you had to use any creams on specifically that foot? Em doesn’t typically include swelling.

#3

Your diagnostic process thus far and symptom onset are not dissimilar to what I experienced, so I will tell you what my doctor did.

I had explosive onset of bilateral erythema of the anterior surface of the knee. It was constant and occurred in regular cycles that were only alleviated by ice application. Symptoms began following a knee injury.

I had all the same blood tests you mentioned and they were negative. I presented similar internet research to my doctors and eventually my insurer sent me to an anesthesiologist, since he specialized in pain disorders.

He did a differential diagnosis for EM and CRPS. I’ll paraphrase his thought process and what he said to me:

Your symptoms are at the knee and occurred following an injury, so that would suggest CRPS. EM is most often found in the feet. However, your symptoms are bilateral and CRPS is typically unilateral. That is more suggestive of EM.

The doctor did a differential diagnosis saying he thought I more likely had CRPS. He ordered a three-phase bone scan with contrast that they use to diagnose CRPS. He also wrote me a prescription for mexiletine, a sodium channel blocker and the oral analog of lidocaine, which has been found to be beneficial to some patients with EM.

The bone scan was normal, while the mexiletine prescription stopped my symptoms. So, it was concluded I have EM.

One major difference between your case and mine is that I had virtually no swelling. I was just having erythema. Considering how the doctor laid it out for me, I think he would probably evaluate you for CRPS. Unilateral swelling and erythema following an injury lines up quite well with CRPS.

#4

I do have an important question:

Have you tried putting your foot in an ice bath when symptoms present? If yes, did the erythema and swelling go away?

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#5

I personally had an apparent case of non painful EM that was due to a hypertensive drug. I don’t think it is your case since you don’t mention any current medication, but after all I don’t know.