Lymphedema is the Most Likely Diagnosis
The positive Stemmer sign (inability to pinch skin at the base of the second toe) combined with bilateral pitting edema extending halfway up the lower legs, in the complete absence of cardiac dysfunction markers (BNP <10 pg/mL, normal E/e' ratio of 8, no jugular venous distension, no orthopnea, no dyspnea), definitively indicates lymphedema rather than cardiac edema. 1
Why This is Lymphedema, Not Heart Failure
The clinical presentation systematically excludes heart failure through multiple independent criteria:
BNP <10 pg/mL essentially rules out heart failure, as the American College of Cardiology states that BNP levels below 100 pg/mL make heart failure unlikely, and your value is 10-fold lower than this threshold 1, 2, 3
E/e' ratio of 8 indicates normal left ventricular filling pressures, as the American Society of Echocardiography defines elevated filling pressures as E/e' >14, and your value is nearly half this cutoff 1
Absence of jugular venous distension excludes volume overload from cardiac causes, as the ACC/AHA guidelines identify jugular venous distension as the most reliable sign of cardiac volume overload 1
The Framingham Heart Failure Diagnostic Criteria require either 2 major criteria or 1 major plus 2 minor criteria, and this patient has none of the major criteria (no orthopnea, no jugular venous distension, no rales, no S3 gallop, no acute pulmonary edema, no cardiomegaly) 1
The Stemmer Sign: Pathognomonic for Lymphedema
A positive Stemmer sign (thickened skin fold at the base of the second toe that cannot be lifted) is highly sensitive for lymphedema and distinguishes it from cardiac edema, according to the 2023 ACC Expert Consensus 1
The examiner's inability to lift the skin of the affected limb reflects fluid accumulation due to lymphatic dysfunction rather than increased hydrostatic pressure from cardiac causes 1
Obesity can cause a false-positive Stemmer sign, but in the context of all other findings excluding cardiac pathology, this remains the correct diagnosis 1
Differential Diagnosis Considerations
The 2023 ACC guidelines provide a systematic approach to edema evaluation by distinguishing between increased hydrostatic pressure (cardiac, cirrhosis, renal failure) versus lymphatic obstruction 1:
Cardiac causes are excluded by normal BNP, normal filling pressures, and absence of all Framingham criteria 1
Cirrhosis with portal hypertension is excluded by the absence of hepatomegaly and the bilateral lower extremity distribution 1
Renal failure would typically present with elevated BNP and other systemic signs, which are absent here 1
Venous insufficiency typically lacks the positive Stemmer sign and would show venous reflux on duplex ultrasound 1
First-Line Management of Lymphedema
Compression Therapy (Primary Treatment)
Compression therapy is the first-line treatment for lymphedema, requiring a minimum pressure of 20-30 mm Hg, with 30-40 mm Hg advised for more severe disease 1:
Negative graduated compression bandages (higher pressure at calf than distal ankle) achieve superior ejection fraction in refluxing vessels and higher extrinsic pressures compared to standard graduated compression 1
Compression therapy reduces edema by decreasing capillary filtration, shifting fluid into non-compressed regions, improving lymphatic drainage, increasing venous blood flow velocity, and improving venous pumping function 1
Evidence demonstrates compression therapy has value in preventing ulcer recurrence (C5 disease) and healing ulcers (C6 disease), though data for C2-C4 disease is limited 1
Additional Management Components
Adherence should be encouraged with proper fitting, education, and detailed instructions, as treatment failure typically results from non-compliance 1
Patients with a negative Stemmer sign but high clinical suspicion for lymphedema warrant referral for lymphoscintigraphy to confirm the diagnosis 1
Complete decongestive therapy includes compression garments, intensive bandaging, and lymphatic massage as the mainstay of conservative management 4
Critical Pitfalls to Avoid
Do not initiate diuretic therapy, as lymphedema results from lymphatic obstruction rather than increased hydrostatic pressure, and diuretics will not address the underlying pathophysiology and may cause electrolyte disturbances 1
Do not pursue cardiac workup beyond what has already been done, as the combination of BNP <10 pg/mL and normal E/e' ratio definitively excludes heart failure as a cause 1
The concentric LV hypertrophy with small end-diastolic volume is a separate finding that may warrant monitoring but is not causing the edema given the normal filling pressures 1
Bilateral presentation does not exclude lymphedema, as primary lymphedema can be bilateral, though it is more commonly unilateral in secondary forms 5, 4