# Elephantiasis Nostra Verrucosa Complicated by Cellulitis and Hemorrhagic Bullae: A Rare and Severe Clinical Presentation

## TL;DR

This paper presents a rare case of severe skin changes in a patient with chronic lymphedema, complicated by infection and unusual bleeding blisters.

## Contribution

The paper reports a rare clinical case of ENV with hemorrhagic bullae, emphasizing early recognition and management.

## Key findings

- ENV can present with severe complications like hemorrhagic bullae due to advanced disease or infection.
- Aggressive conservative measures are critical for managing lymphatic dysfunction and preventing progression.
- Atypical skin findings in chronic lymphedema require prompt evaluation to avoid serious complications.

## Abstract

Elephantiasis nostras verrucosa (ENV) is a rare and debilitating manifestation of chronic nonfilarial lymphedema characterized by progressive dermal fibrosis, hyperkeratosis, and papillomatous skin changes. It arises from long-standing lymphatic obstruction and is most commonly associated with risk factors such as obesity, venous insufficiency, recurrent soft tissue infections, and conditions impairing lymphatic drainage. The true prevalence of ENV is poorly defined due to its rarity, though limited institutional data suggest it is uncommon even among high-risk populations. While ENV typically presents as slowly progressive limb enlargement with characteristic skin changes, atypical features may indicate advanced disease or superimposed infection. We report the case of a 48-year-old male with chronic lower-extremity lymphedema complicated by recurrent cellulitis who developed progressive cutaneous changes consistent with evolving ENV and was further complicated by the appearance of hemorrhagic bullae. This uncommon finding raised concern for severe infection and potential vascular compromise. Management focused on treating acute bacterial cellulitis while addressing the underlying lymphatic dysfunction through aggressive conservative measures. This case highlights the importance of early recognition of atypical skin findings in chronic lymphedema and reinforces the central role of lymphedema control in preventing disease progression and serious complications.