SHM Converge Scientific Abstract ePoster Gallery-Puffy Hands: Lymphatic Obstruction From Intravenous Drug Use

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This case describes a 30-year-old woman with progressive, painless bilateral hand swelling that began after childbirth and worsened over three years. Her symptoms included nail thinning, bruising, reduced finger dexterity, intermittent fluid leakage, and poorly healing wounds, but she had no joint pain, weakness, sensory loss, skin thickening, or systemic symptoms suggestive of connective tissue disease. She had a history of remote intravenous heroin use.<br /><br />She was initially evaluated by rheumatology and treated as though she had systemic lupus erythematosus, receiving prednisone, azathioprine, mycophenolate, and belimumab without improvement. On exam, she had diffuse pitting edema of both hands and fingers with blanchable erythema and limited finger movement, but no tenderness, warmth, or neurologic deficits. Laboratory testing was largely normal, including inflammatory markers, complements, and most autoimmune serologies; ANA was only weakly positive. Hand radiographs showed no bone or inflammatory joint abnormalities.<br /><br />The final diagnosis was puffy hand syndrome (PHS), a rare form of lymphatic obstruction caused by inflammation and fibrosis from repeated superficial injection of toxic substances. Major risk factors include use of the hands or feet for injection, female sex, and pregnancy. There is no curative therapy. Management focuses on symptom relief and harm reduction through compression, elastic garments, lymphatic massage, and reducing unsafe injection practices.<br /><br />The authors emphasize that clinicians, especially hospitalists, should recognize PHS in patients with a history of IV drug use to avoid unnecessary workups and inappropriate immunosuppressive treatment.

Asset Subtitle

Shelief Robbins-Juarez

Meta Tag

Author List Shelief Robbins-Juarez, Vinay Choksi

Category Clinical Vignettes

Concept Puffy Hands

Concept Intravenous Drug Use

Concept Lymphatic Obstruction

Concept Hand Swelling

Concept Hand Edema

Distinguished Non-Finalist

Presenter Organization Duke University Hospital

Presenting Author Shelief Robbins-Juarez

Track Adult

Keywords

puffy hand syndrome

bilateral hand swelling

intravenous drug use

lymphatic obstruction

pitting edema

hand edema

female sex

pregnancy

immunosuppressive misdiagnosis

harm reduction

Puffy Hands

Intravenous Drug Use

Lymphatic Obstruction

Hand Swelling

Hand Edema