The Cellulitis That Kept Coming Back

A 34-year-old woman from Sarawak, Malaysia who immigrated to the United States 5 years ago presents to the infectious diseases clinic for evaluation of recurrent left lower leg swelling. Over the past 3 years she has had six to seven episodes of painful, erythematous swelling of the left lower leg and foot accompanied by fever and chills, each lasting 5 to 10 days. She was diagnosed with cellulitis on each occasion and treated with antibiotics; symptoms improved partially but the swelling between episodes never fully resolved.

Approximately 6 months ago she noticed a tender, rubbery nodule in the left inguinal region. Over several weeks it enlarged, became fluctuant, and spontaneously drained a small amount of clear fluid. It was not biopsied. The wound healed over the following weeks, leaving a firm scar. She has no history of trauma, prior surgery, or malignancy. She takes no medications. She grew up in a rural agricultural area near Kuching and spent significant time outdoors near stagnant water and rice fields before emigrating.

On examination she is afebrile with normal vital signs. There is non-pitting edema of the left lower leg and foot extending from the ankle to just below the knee; the thigh and remainder of the left leg are unaffected. The skin over the affected area is thickened but without ulceration. There are enlarged, firm, non-tender left inguinal lymph nodes and a well-healed scar in the left inguinal crease. The remainder of the examination is unremarkable.

Complete blood count shows hemoglobin 12.8 g/dL, white blood cell count 9,200/μL with an absolute eosinophil count of 1,100/μL, and platelets 228,000/μL. Comprehensive metabolic panel is within normal limits. A peripheral blood smear obtained at 2 PM during the clinic visit reveals no microfilariae.