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Lymphangitis

BASICS

DESCRIPTION

- Acute infection - Usually caused by group A Ž ²-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.

- 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

- Drug interactions - Methotrexate, venlafaxine, warfarin, hormonal contraceptives

- Contraindications - Hypersensitivity to penicillin

- 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

- 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)

- 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

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 infectionUsually caused by group A Ž ²-hemolytic StreptococcusLess commonly caused by:Staphylococcus aureusPasteurella multocidaErysipelothrixSpirillum minus (rat bite disease)PseudomonasOther Streptococcus sp.Immunocompromised patients can be infected with gram-negative rods, gram-negative bacilli, or fungi.In fresh water exposures, Aeromonas hydrophila
  • Nodular lymphangitisAlso known as sporotrichoid lymphangitisPresents as painful or painless nodular subcutaneous swellings along lymphatic vesselsLesions may ulcerate with accompanying regional lymphadenopathy.Typical of infections from the following: Sporothrix schenckii, Nocardia brasiliensis, Mycobacterium marinum, leishmaniasis, tularemia, and systemic mycosesPathology may show granulomas.
  • Noninfectious granulomatous lymphangitisRare-acquired lymphedema of the genitalia in childrenMay be due to atypical Crohn disease or sarcoidosis (1)[C]
  • Filarial lymphangitisMosquito bites transmit parasites causing inflammation and dilatation in the lymphatic vessels; can predispose to secondary bacterial infectionUsually caused by nematodes Wuchereria bancrofti. Other causes are Brugia malayi and Brugia timori.
  • Lymphangitis due to surgeryMay occur after surgical procedures and lymph node dissection
  • Cutaneous lymphangitis carcinomatosa is rare. Represents ¢ ˆ ¼5% of all skin metasteses; caused by occlusion of lymphatic channels of dermis by neoplastic cells (2)
  • Sclerosing lymphangitis of the penisSwelling 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)

DIAGNOSIS

HISTORY

  • History of trauma to skin, cut, abrasion, or fungal infection
  • Systemic symptoms:MalaiseFever and chillsLoss of appetiteHeadacheMuscle aches
  • Travel to a tropical region or region with known filariasis

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 thrombophlebitisThrombus 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

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 Ž ²-hemolytic Streptococcus is suspected, treat aggressively with antibiotics and surgical intervention.

First Line

  • Antibiotics for group A streptococcal infectionAmoxicillin (if patient known to have only group A Streptococcus)DosingAdultsMild to moderate: 500 mg PO q12hSevere: 875 mg PO q12h or 500 mg PO q8hChildren <3 months: 30 mg/kg/day PO divided q12hChildren ≥3 months, ≤40 kgMild to moderate: 25 mg/kg/day PO divided q12h or 20 mg/kg/day divided q8hSevere: 45 mg/kg/day PO divided q12h or 40 mg/kg/day divided q8hChildren ≥40 kg same as adult dosingCommon adverse effectsSerious adverse effectsAnaphylaxis, Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN)Drug interactionsMethotrexate, venlafaxine, warfarin, hormonal contraceptivesContraindicationsHypersensitivity to penicillin
  • Ampicillin/sulbactamDosingAdults and children ≥40 kg: 1.5 to 3 g (ampicillin + sulbactam component) IV/IM q6hChildren <40 kg: 200 mg/kg/day IV infusion, in divided doses q6h; maximum 8 g ampicillin per dayCommon adverse effectsDiarrhea, injection site reactionsSerious adverse effectsClostridium difficile diarrhea, pseudomembranous enterocolitisDrug interactionsContraindicationsHypersensitivity reactions
  • CeftriaxoneDosingAdults: 1 to 2 g IV/IM q24hChildren: 50 to 75 mg/kg/day IV/IM once daily or in divided doses q12h; maximum 2 g/dayCommon adverse effectsInjection site reactions, diarrheaSerious adverse effects: same as amoxicillin or ampicillinDrug interactionsDo not administer calcium-containing solutions in the same IV line.ContraindicationsHypersensitivity to cephalosporinsConcurrent calcium-containing IV fluidsIncreased risk of kernicterus, salt precipitation in lungs and kidneys in neonates <28 days (use cefotaxime instead)
  • CephalexinDosingAdults: 500 mg PO q12hChildren: 25 to 50 mg/kg/day divided q12hCommon adverse effectsSerious adverse effectsSJS, TEN, interstitial nephritis, renal failure, pseudomembranous enterocolitis, anaphylaxisContraindicationsHypersensitivity to cephalosporins
  • Azithromycin (if penicillin or cephalosporin allergy)DosingAdults: 500 mg PO on day 1 followed by 250 mg/day PO on days 2 to 5Children ≥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 effectsAbdominal pain, nausea, vomiting, diarrhea, headacheSerious adverse effectsProlonged QT interval, torsades de pointes, liver failure, Lambert-Eaton syndrome, myasthenia gravis, corneal erosion, anaphylaxisDrug interactionsNelfinavir, warfarin, other medications with potential to prolong QT intervalContraindicationsHepatic dysfunction or cholestatic jaundice with prior treatmentHypersensitivity 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 debridement
  • 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. ‚

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

COMPLICATIONS

Sepsis, cellulitis, necrotizing fasciitis, myositis ‚

REFERENCES

11 Taylor ‚ MJ, Hoerauf ‚ A, Bockarie ‚ M. Lymphatic filariasis and onchocerciasis. Lancet. 2010;376(9747):1175 " “1185.22 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 " “93.33 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 " “FC08.44 Falagas ‚ ME, Bliziotis ‚ IA, Kapaskelis ‚ AM. Red streaks on the leg. Lymphangitis. Am Fam Physician. 2006;73(6):1061 " “1062.55 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

  • 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

ICD10

  • I89.1 Lymphangitis
  • L03.91 Acute lymphangitis, unspecified
  • N48.29 Other inflammatory disorders of penis
  • B74.0 Filariasis due to Wuchereria bancrofti
  • B74.1 Filariasis due to Brugia malayi
  • B74.2 Filariasis due to Brugia timori

ICD9

  • 457.2 Lymphangitis
  • 682.9 Cellulitis and abscess of unspecified sites
  • 607.2 Other inflammatory disorders of penis
  • 125.0 Bancroftian filariasis
  • 125.1 Malayan filariasis

SNOMED

  • 1415005 Lymphangitis (disorder)
  • 8838005 Acute lymphangitis (disorder)
  • 78973009 Chronic lymphangitis (disorder)
  • 91586009 Bancroftian elephantiasis (disorder)
  • 361279005 Sclerosing lymphangitis of penis (disorder)
  • 7066000 Infectious lymphangitis (disorder)
  • 19661000 Malayan elephantiasis (disorder)

CLINICAL PEARLS

  • 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.