Lymphangitis

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 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.
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 ¢ ˆ ¼5% of all skin metasteses; 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)

DIAGNOSIS

HISTORY

History of trauma to skin, cut, abrasion, or fungal infection
Systemic symptoms:
- Malaise
- Fever and chills
- Loss of appetite
- Headache
- Muscle 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 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

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 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
    - 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 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.

Home

Erectile Dysfunction

Doctor123.org