title: Bilateral lower extremity inflammatory lymphedema in Air Force basic trainees: clinical and epidemiologic study of a new disease entity.
abstract: OBJECTIVE
  This observational study characterizes a new clinical condition identified in 55 military trainees.
  
  
  OBJECTIVE
  To determine the incidence and underlying cause of bilateral lower extremity inflammatory lymphedema in Air Force basic trainees.
  
  
  METHODS
  An observational study was conducted at Lackland Air Force Base in San Antonio, Texas. Participants included 14 243 Air Force basic trainees who entered training between September 2011 and January 2012 and the 55 trainees (0.4%) who developed bilateral lower extremity inflammatory lymphedema that occurred during the 8½-week basic training course. Two modifiable risk factors were evaluated: vaccine reaction and newly issued military footwear (combat boots and boot socks).
  
  
  METHODS
  During November 2011, all new trainees wore only white socks and running shoes rather than the issued military footwear. During December 2011 and January 2012, the scheduled administration of tetanus/diphtheria/acellular pertussis and meningococcal vaccines, respectively, was delayed by 1 week for all new trainees. A full medical record review was conducted for every confirmed case of bilateral lower extremity inflammatory lymphedema.
  
  
  METHODS
  Identification of incident cases, symptom onset, antimicrobial treatment, immunization reaction, laboratory studies, specialty referral, and biopsy.
  
  
  RESULTS
  Fifty-four of the 55 incident cases (98%) of bilateral lower extremity inflammatory lymphedema occurred during the first 120 hours of training. Alterations in the timing of the military footwear used and selected vaccine administration had no effect on the incidence of new cases. Two participants (4%) experienced symptom onset before receipt of the vaccines. Oral antimicrobial medications were not found to speed symptom resolution compared with conservative treatment measures (P = .34). One incident case was diagnosed as leukocytoclastic vasculitis by tissue examination.
  
  
  CONCLUSIONS
  Multiple training-related risk factors were ruled out as sources of bilateral lower extremity inflammatory lymphedema. Cases are likely secondary to prolonged standing with resultant gravity-dependent venous congestion and inflammatory vasculitis. The potential roles of undiagnosed venous reflux disease and the military physical training environment in these cases remain to be elucidated.
authors.affiliation: 10th Aeromedical Squadron, US Air Force Academy, Colorado Springs, Colorado.
authors.forename: Kevin A
authors.initials: KA
authors.lastname: Fajardo
authors.affiliation: US Air Force Medical Support Agency, San Antonio, Texas.
authors.forename: Patrick
authors.initials: P
authors.lastname: Keller
authors.affiliation: 59th Medical Wing Dermatology Clinic, Joint Base San Antonio, Lackland Air Force Base, San Antonio, Texas.
authors.forename: Todd
authors.initials: T
authors.lastname: Kobayashi
authors.affiliation: 59th Medical Wing Dermatology Clinic, Joint Base San Antonio, Lackland Air Force Base, San Antonio, Texas.
authors.forename: Chad M
authors.initials: CM
authors.lastname: Hivnor
authors.affiliation: 559th Medical Operations Squadron, Joint Base San Antonio, Lackland Air Force Base, San Antonio, Texas.
authors.forename: Bryant J
authors.initials: BJ
authors.lastname: Webber
authors.affiliation: 559th Medical Operations Squadron, Joint Base San Antonio, Lackland Air Force Base, San Antonio, Texas.
authors.forename: Susan P
authors.initials: SP
authors.lastname: Federinko
authors.affiliation: 559th Medical Operations Squadron, Joint Base San Antonio, Lackland Air Force Base, San Antonio, Texas.
authors.forename: Juste
authors.initials: J
authors.lastname: Tchandja
mesh_terms: D005260:Female; D006112:Gravitation; D006801:Humans; D015994:Incidence; D007249:Inflammation / Q000453:epidemiology / Q000209:etiology* / Q000473:pathology; D035002:Lower Extremity; D008209:Lymphedema / Q000453:epidemiology / Q000209:etiology* / Q000473:pathology; D008297:Male; D008889:Military Personnel; D012307:Risk Factors; D012775:Shoes; D013997:Time Factors; D014481:United States