Clinical Reasoning: A 50-year-old man with "elephantiasis" and headache

A 50-year-old man with a medical history of elephantiasis of the legs, status post left above the knee amputation with prosthetic limb, and hypothyroidism presented with 1 week of headache and nausea. The headache was continuous, with gradual worsening over the 7 days prior to admission, and he had minimal relief with ibuprofen. On the second day, he developed nausea. He denied any history of headaches, blurred or double vision, numbness, weakness, tingling, loss of balance, vertigo, chest pain, palpitations, or shortness of breath. In the emergency room, he was afebrile with a heart rate of 78 beats per minute and regular, and a blood pressure of 132/78 mm Hg. General physical examination revealed right leg hypertrophy with hyperpigmentation, and edema more prominent distally (tree-barking) (figure 1). A comprehensive neurologic examination had normal results. Basic laboratory tests including complete blood count, basic metabolic panel, and thyroid tests were within normal limits. Head CT showed a hypodensity in the left cerebellar hemisphere (figure 1).