MF, a 43-year-old man with a history of Crohn’s disease, has been experiencing discogenic low back pain. He underwent assessment at a tertiary care centre and was felt to be a non-surgical case with an element of functional component. He was started on pain control with gabapentin, baclofen, morphine, doxepin and sent back to the local hospital for rehabilitation.

Over the next 6-8 weeks, he noted progressive increase in leg swelling. In the last fortnight, he gained 5 kg. He also noted some decrease in urine output but denied difficulty with passing urine. He was started on furosemide without much effect. He now describes itching over his legs for the past week without rash or skin breakdown. He denies shortness of breath, orthopnea or paroxysmal nocturnal dyspnea.

He has been a smoker for 20 years but doesn’t use alcohol. His current medications are morphine SR 75 mg every 8 hours, gabapentin 600 mg every 6 hours, baclofen, doxepin and tamsulosin.

Physical examination reveals a man of stated age, average built, with blood pressure of 142/76 mm Hg with regular rhythm. Jugular venous pressure isn’t elevated. His heart sounds are normal and his lungs clear. MF’s abdomen is soft and non-tender without ascites. There’s a trace of chronic sacral edema. There’s bilateral swelling of both lower extremities with some pitting but more so induration or lymphedema.

Lab data revealed normal hemoglobin, normal albumin of 42 g/L, normal AST, ALT with slightly elevated GGT of 88, BUN of 8.5 mmol/L with serum creatinine of 100 μmol/L and a urinalysis was negative for protein. An ECG showed sinus rhythm and chest x-ray was unremarkable. An echocardiogram was unremarkable, with grade 1 LV function. Venous Doppler of both lower extremities was negative for DVT. A CT scan of the abdomen was also unremarkable, save for mild fatty change in his liver.