This is somewhat of Aunt Minnie diagnosis. On first inspection the images of the bone isotope study demonstrate extensive non-osseous uptake in the lower limbs below the knee. This resembles skin contamination but it can be seen that the uptake is symmetrical and comparable on anterior and posterior images. There is also no uptake related to the urinary catheter which would be expected in skin urinary contamination. The history states obesity and the images clearly demonstrate that there is a symmetrical excess of soft tissues and that unusually this is more prominent in the lower limbs than in the upper torso. This distribution of peripheral uptake is characteristic of lymphoedema. While bone isotope imaging is not a typical test for evaluation of this entity it is worth recognising the distinct appearances. More usually patients are evaluated by lymphoscintigraphy to evaluate the distribution of nodes and lymphatic channels, this being a replacement to the lost art of lymphography. Pelvic MRI can be used to evalaute both the presence of unusual lymphatic dilatations or of alternative pathology due to compressive pathology on the venous system. More superiorly CT or MR can evaluate venous compression or pathology near the expected location of the cisterna chyli or thoracic duct in the posterior mediastinum.
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