# Inflammatory Lymphedema Masquerading as Bilateral Cellulitis: A Military Dilemma

## TL;DR

A new condition called BLEIL, often mistaken for cellulitis in military recruits, can be resolved quickly with proper treatment instead of unnecessary antibiotics.

## Contribution

The paper introduces BLEIL as a novel clinical entity and highlights its misdiagnosis as cellulitis in military recruits.

## Key findings

- BLEIL presents with bilateral foot and ankle erythema and edema after prolonged standing in recruits.
- Prompt venous decongestive therapy resolved symptoms and allowed return to training without recurrence.
- BLEIL is frequently misdiagnosed as cellulitis, leading to unnecessary antibiotic use.

## Abstract

Bilateral lower extremity inflammatory lymphedema (BLEIL) is a novel condition characterized by confluent erythema and painful edema prominent to the dorsum of the feet and ankles bilaterally following prolonged standing and marching, occurring most often in military recruits. Prolonged standing during the initial week of basic training is thought to cause venous congestion and subsequent inflammatory vasculitis. This condition may be misdiagnosed as bilateral cellulitis, prompting the initiation of unnecessary antibiotic therapy. Increased education and recognition of this new clinical entity would lead to the initiation of appropriate therapy and earlier symptom resolution and, thus, an earlier return to military training.

Herein, we describe a small case series of Marine Corps recruit members undergoing their first week of basic training (i.e., "processing week") who developed bilateral lower extremity edema, erythema, and pain localized to the dorsum of the feet and the medial and lateral aspects of the ankles consistent with the diagnosis of BLEIL but were initially diagnosed with bilateral lower extremity cellulitis and received intravenous antimicrobial therapy. With prompt initiation of venous decongestive therapy with leg elevation, both patients had rapid symptom resolution and returned to basic training without any future episodes of symptoms. These cases add to the paucity of data on this clinical entity, illustrate the symptoms and demographics of BLEIL, and describe the importance of recognition and initiation of appropriate therapy.