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Lymphangitis
Amar Kapur, DO, CPT, MC, USA
image BASICS
DESCRIPTION
Acute or chronic inflammation of lymphatic channels due to a skin breach or local trauma. Presents as red, tender streaks along lymphatic channels and extending to regional lymph nodes
  • May result from compromised lymphatic drainage due to surgical procedures
  • May be infectious or noninfectious
ETIOLOGY AND PATHOPHYSIOLOGY
  • Acute infection
    • Usually caused by group A &bgr;-hemolytic Streptococcus
    • Less commonly caused by:
      • Staphylococcus aureus
      • Pasteurella multocida
      • Erysipelothrix
      • Spirillum minus (rat bite disease)
      • Pseudomonas
      • Other Streptococcus sp.
      • Immunocompromised patients can be infected with gram-negative rods, gram-negative bacilli, or fungi.
      • In fresh water exposures, Aeromonas hydrophila
  • Nodular lymphangitis
    • Also known as sporotrichoid lymphangitis
    • Presents as painful or painless nodular subcutaneous swellings along lymphatic vessels
    • Lesions may ulcerate with accompanying regional lymphadenopathy.
    • Typical of infections from the following: Sporothrix schenckii, Nocardia brasiliensis, Mycobacterium marinum, leishmaniasis, tularemia, and systemic mycoses
    • Pathology may show granulomas.
  • Noninfectious granulomatous lymphangitis
    • Rare-acquired lymphedema of the genitalia in children
    • May be due to atypical Crohn disease or sarcoidosis (1)[C]
  • Filarial lymphangitis
    • Mosquito bites transmit parasites causing inflammation and dilatation in the lymphatic vessels; can predispose to secondary bacterial infection
    • Usually caused by nematodes Wuchereria bancrofti. Other causes are Brugia malayi and Brugia timori.
  • Lymphangitis due to surgery
    • May occur after surgical procedures and lymph node dissection
  • Cutaneous lymphangitis carcinomatosa is rare. Represents ˜5% of all skin metastases; caused by occlusion of lymphatic channels of dermis by neoplastic cells (2)
  • Sclerosing lymphangitis of the penis
    • Swelling around coronal sulcus of penis usually resulting from vigorous sexual activity or masturbation
RISK FACTORS
  • Impaired lymphatic drainage due to surgery, nodal dissection, or irradiation
  • Diabetes mellitus
  • Chronic steroid use
  • Peripheral venous catheter
  • Varicella infection
  • Immunocompromising condition
  • Human, animal, or insect bites
  • Fungal, bacterial, or mycobacterial skin infections
  • Any trauma to the skin
  • IV drug abuse
  • Residence in endemic areas of filariasis
GENERAL PREVENTION
  • Reduce chronic lymphedema with compression devices or by treating underlying process
  • Insect repellant
  • Proper wound and skin care
COMMONLY ASSOCIATED CONDITIONS
  • Lymphedema
  • Prior lymph node dissection
  • Tinea pedis (athlete's foot)
  • Sporotrichosis
  • Cellulitis, erysipelas
  • Filarial infection (W. bancrofti)
image DIAGNOSIS
PHYSICAL EXAM
Local signs:
  • Erythematous, macular linear streaks from site of infection toward the regional lymph nodes
  • Tenderness and warmth over affected skin or lymph nodes
  • May have blistering of affected skin
  • Fluctuance, swelling, or purulent drainage
  • Nodular lymphangitis can present with subcutaneous swellings along the lymphatic channels.
  • Sporotrichosis may present with papulonodular lesions that may ulcerate.
  • Sites may be nonpainful.
DIFFERENTIAL DIAGNOSIS
  • Superficial thrombophlebitis
    • Thrombus or infection within the thrombosis (septic thrombophlebitis)
  • Contact dermatitis
  • Allergic reaction: less likely to be allergic if >24 hours after exposure (e.g., insect bite)
  • Lymphangitis carcinomatosa
  • Malignancy-related inflammation
DIAGNOSTIC TESTS & INTERPRETATION
  • CBC may show leukocytosis; blood smear may show filarial infection.
  • Blood or wound cultures
  • Biopsy cultures
  • FNAC for filariasis of testiculoscrotal swelling but not for other superficial locations (3)
Initial Tests (lab, imaging)
Plain radiology unnecessary; may consider lymphangiography for lymphedema (4)[C]
Diagnostic Procedures/Other
  • Swab, aspirate, and/or biopsy primary site, purulent discharge, nodule or distal ulcer for culture, acid fast staining, histology, and microscopy
  • Blood cultures if systemically ill
  • Serology (e.g., Francisella tularensis, histoplasma)
  • Blood film/smear (e.g., filaria)
  • Lymphangiography to determine lymphedema or lymphatic obstruction
image TREATMENT
GENERAL MEASURES
  • Hot, moist compresses to affected area
  • If lymphedema is involved, compression garments and weight loss may help.
  • Abstinence from sexual activity (for sclerosing lymphangitis)
MEDICATION
  • Treat common organisms empirically. Use culture and susceptibility to guide subsequent antibiotic treatment (5)[B].
  • If mild disease, use outpatient oral antibiotics.
  • If no improvement after 48 hours of oral antibiotics, reassess and consider IV antibiotics and/or hospitalization.
  • If systemic involvement, start IV antibiotics.
  • If necrotizing fasciitis due to group A &bgr;-hemolytic Streptococcus is suspected, treat aggressively with antibiotics and surgical intervention.
First Line
  • Antibiotics for group A streptococcal infection
    • Amoxicillin (if patient known to have only group A Streptococcus)
      • Dosing
        • Adults
          • Mild to moderate: 500 mg PO q12h
          • Severe: 875 mg PO q12h or 500 mg PO q8h
        • P.625

        • Children <3 months: 30 mg/kg/day PO divided q12h
        • Children ≥3 months, ≤40 kg
          • Mild to moderate: 25 mg/kg/day PO divided q12h or 20 mg/kg/day divided q8h
          • Severe: 45 mg/kg/day PO divided q12h or 40 mg/kg/day divided q8h
        • Children ≥40 kg same as adult dosing
      • Common adverse effects
        • Diarrhea
      • Serious adverse effects
        • Anaphylaxis, Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN)
      • Drug interactions
        • Methotrexate, venlafaxine, warfarin, hormonal contraceptives
      • Contraindications
        • Hypersensitivity to penicillin
  • Ampicillin/sulbactam
    • Dosing
      • Adults and children ≥40 kg: 1.5 to 3 g (ampicillin + sulbactam component) IV/IM q6h
      • Children <40 kg: 200 mg/kg/day IV infusion, in divided doses q6h; maximum 8 g ampicillin per day
    • Common adverse effects
      • Diarrhea, injection site reactions
    • Serious adverse effects
      • Clostridium difficile diarrhea, pseudomembranous enterocolitis
    • Drug interactions
      • Hormonal contraceptives
    • Contraindications
      • Hypersensitivity reactions
  • Ceftriaxone
    • Dosing
      • Adults: 1 to 2 g IV/IM q24h
      • Children: 50 to 75 mg/kg/day IV/IM once daily or in divided doses q12h; maximum 2 g/day
    • Common adverse effects
      • Injection site reactions, diarrhea
    • Serious adverse effects: same as amoxicillin or ampicillin
    • Drug interactions
      • Do not administer calcium-containing solutions in the same IV line.
    • Contraindications
      • Hypersensitivity to cephalosporins
      • Concurrent calcium-containing IV fluids
      • Increased risk of kernicterus, salt precipitation in lungs and kidneys in neonates <28 days (use cefotaxime instead)
  • Cephalexin
    • Dosing
      • Adults: 500 mg PO q12h
      • Children: 25 to 50 mg/kg/day divided q12h
    • Common adverse effects
      • Diarrhea
    • Serious adverse effects
      • SJS, TEN, interstitial nephritis, renal failure, pseudomembranous enterocolitis, anaphylaxis
    • Contraindications
      • Hypersensitivity to cephalosporins
  • Azithromycin (if penicillin or cephalosporin allergy)
    • Dosing
      • Adults: 500 mg PO on day 1 followed by 250 mg/day PO on days 2 to 5
      • Children ≥2 years: 12 mg/kg/day PO (maximum dose: 500 mg/day) once daily for 5 days (FDA off-label use for skin infections in children)
    • Common adverse effects
      • Abdominal pain, nausea, vomiting, diarrhea, headache
    • Serious adverse effects
      • Prolonged QT interval, torsades de pointes, liver failure, Lambert-Eaton syndrome, myasthenia gravis, corneal erosion, anaphylaxis
    • Drug interactions
      • Nelfinavir, warfarin, other medications with potential to prolong QT interval
    • Contraindications
      • Hepatic dysfunction or cholestatic jaundice with prior treatment
      • Hypersensitivity to macrolide (azithromycin, erythromycin, clarithromycin)
  • Diethylcarbamazine, ivermectin, albendazole, and doxycycline are used to treat filarial infection.
  • Acetaminophen or ibuprofen (NSAIDs) for pain and fever
SURGERY/OTHER PROCEDURES
  • Incision and drainage of abscess if present
  • Necrotizing fasciitis needs surgical evaluation and likely débridement
  • Nodular lymphangitis may benefit from I&D
  • With severe lymphedema, consider surgical drainage
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Admit for signs of serious illness: fluids if in hypotensive shock.
  • Fever, chills, systemic toxicity
  • IV antibiotics
  • ICU or surgery as indicated
Discharge Criteria
Patient can be discharged on oral antibiotics after systemic symptoms resolve. Home IV antibiotics are an option depending on clinical setting.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Elevate affected area.
  • 48-hour follow-up to ensure improvement
  • Recurrent lymphangitis should prompt workup to ascertain underlying cause (other infectious organism, anatomic abnormality, etc.).
Patient Monitoring
Close follow-up to ensure decreasing inflammation
PATIENT EDUCATION
Instruct patients on proper wound and skin care.
PROGNOSIS
  • Good prognosis for uncomplicated cases
  • Antimicrobial therapy is effective in 90% of patients.
  • Untreated, can spread rapidly, especially group A Streptococcus
REFERENCES
1. Taylor MJ, Hoerauf A, Bockarie M. Lymphatic filariasis and onchocerciasis. Lancet. 2010;376(9747):1175-1185.
2. Prat L, Chouaid C, Kettaneh A, et al. Cutaneous lymphangitis carcinomatosa in a patient with lung adenocarcinoma: case report and literature review. Lung Cancer. 2013;79(1):91-93.
3. Khare P, Kala P, Jha A, et al. Incidental diagnosis of filariasis in superficial location by FNAC: a retrospective study of 10 years. J Clin Diagn Res. 2014;8(12):FC05-FC08.
4. Falagas ME, Bliziotis IA, Kapaskelis AM. Red streaks on the leg. Lymphangitis. Am Fam Physician. 2006;73(6):1061-1062.
5. Badger C, Seers K, Preston N, et al. Antibiotics/anti-inflammatories for reducing acute inflammatory episodes in lymphoedema of the limbs. Cochrane Database Syst Rev. 2004;(2):CD003143.
Additional Reading
&NA;
  • Babu AK, Krishnan P, Andezuth DD. Sclerosing lymphangitis of penis—literature review and report of 2 cases. Dermatol Online J. 2014;20(7):9.
  • Edlich RF, Winters KL, Britt LD, et al. Bacterial diseases of the skin. J Long Term Eff Med Implants. 2005;15(5):499-510.
  • Raja A, Seshadri RA, Sundersingh S. Lymphangitis carcinomatosa: report of a case and review of literature. Indian J Surg Oncol. 2010;1(3):274-276.
  • Schubach A, Barros MB, Wanke B. Epidemic sporotrichosis. Curr Opin Infect Dis. 2008;21(2):129-133.
Codes
&NA;
ICD10
  • I89.1 Lymphangitis
  • L03.91 Acute lymphangitis, unspecified
  • N48.29 Other inflammatory disorders of penis
Clinical Pearls
&NA;
  • Lymphangitis classically presents with erythematous linear streaks of the skin from the inciting site (e.g., bite, cut, abrasion) to regional lymph nodes.
  • Patients with prior surgical lymph node dissection are predisposed to lymphangitis.
  • Patients with severe systemic symptoms should be admitted and treated with IV antibiotics.
  • Parasitic or fungal infections can cause acute or chronic lymphangitis.
  • Treatment of underlying skin infection (such as tinea pedis) may prevent recurrence.