An unusual case of pedal edema

A 40-year-old male patient reported to medical outpatient department with bilateral pedal edema of 15 days duration which was progressive, bilaterally symmetrical, pitting and with minimal pain and redness. Examination revealed pallor and bilateral pitting pedal edema with mild tenderness. Investigations revealed dimorphic anemia with reduced vitamin B12 levels. All other biochemical and radiological including radiograph of the chest, ultrasonography of abdomen, color doppler of the both lower limbs, and two dimensional echocardiography were normal. For the next one month, the patient showed significant improvement and was discharged. Fifteen days later, the patient was again readmitted with progressively worsening breathlessness with orthopnea and increasing pedal edema of two days duration. Clinically and radiologically, patient had features of congestive cardiac failure which was corroborated with markedly raised levels of NT pro brain natriuretic peptide. He also had other organ involvement with raised serum creatinine (1.9 mg/dl) and elevated transaminases of >300 IU/L. Patient was managed with high flow oxygen, ventilatory support, intravenous loop diuretics, low-dose angiotensin-converting enzyme inhibitors, and supportive care. The next day, patient's son and wife also reported with bilateral pedal edema and breathlessness. Based on this history, the diagnosis of epidemic dropsy was suspected. Mustard oil from their kitchen tested positive for nitric oxide test which was later confirmed at Public Health Laboratory. The index case showed progressive downhill course and died after 3 days. Both son and wife recovered over the next few months.