64-year-old obese man (BMI-34.2) with past medical history chronic kidney disease stage II presented to the emergency department with left lower extremity pain and redness. Patient has been having chronic worsening lymphedema and skin changes of the left lower extremity since 10 years.

On examination patient was found to have chronic lymphedema with erythema and thickened verrucous skin of the left lower extremity. Left leg also had open ulceration with drainage of serosanguineous fluid.

Labs showed increased CRP 95.87, leukocytosis 24.1 and elevated lactic acid of 4.5 which improved with fluid resuscitation. Lower extremity duplex didn’t show any evidence of deep vein thrombosis. Patient was managed with antibiotics and was discharged home to follow-up with lymphedema and wound clinic.

Elephantiasis nostra verrucosa is a rare sequela of chronic lymphedema. Diagnosis usually made clinically based on the history of chronic lymphedema and chronic skin changes. It is characterized by hyperkeratotic popular nodules with cobblestone-like appearance.