Lymphangitis, Emergency Medicine

Basics

Description

Lymphangitis is the infection of lymphatics that drain a focus of inflammation
Histologically, lymphatic vessels are dilated and filled with lymphocytes and histiocytes:
- Inflammation frequently extends into perilymphatic tissues and may lead to cellulitis or abscess formation

Etiology

Acute lymphangitis:
- Likely caused by bacterial infection
- Most commonly group A ²-hemolytic Streptococcus
- Less commonly due to other strep groups, and occasionally Staphylococcus aureus, including resistant strains such as community-associated methicillin-resistant S. aureus (CA-MRSA):
  - CA-MRSA risk factors: Prior MRSA infection, household contact of CA-MRSA patient, military personnel, incarcerated persons, athletes in contact sports, IV drug users, men who have sex with men
  - Different antibiotic susceptibility than nosocomial MRSA
  - CA-MRSA now sufficiently prevalent to warrant empiric treatment
  - Suspect CA-MRSA in unresponsive infections or if multiple or recurrent abscesses
- Other organisms:
  - Pasteurella multocida (cat or dog bite)
  - Spirillum minus (rat-bite fever)
  - Wuchereria bancrofti (filariasis): Consider in immigrants from Africa, Southeast Asia/Pacific, and tropical South America with lower-extremity involvement
Chronic lymphangitis:
- Usually caused by mycotic, mycobacterial, and filarial infections
- Sporothrix schenckii (most common cause of chronic lymphangitis in US):
  - Inoculation occurs while gardening or farming (rose thorn)
  - Organism is present on some plants and in sphagnum moss
  - Multiple SC nodules appear along course of lymphatic vessels
  - Typical antibiotics and local treatment fail to cure lesion
- Mycobacterium marinum:
  - Atypical Mycobacterium
  - Grows optimally at 25 " 32 °C in fish tanks and swimming pools
  - May produce a chronic nodular, single wart-like or ulcerative lesion at site of abrasion
  - Additional lesions may appear in distribution similar to sporotrichosis
- Nocardia brasiliensis
- Mycobacterium kansasii
- W. bancrofti

Diagnosis

Signs and Symptoms

Acute lymphangitis:
- Warm, tender erythematous streaks develop and extend proximally from the source of infection
- Regional lymph nodes often become enlarged and tender (lymphadenitis).
- Peripheral edema of involved extremity
- Systemic manifestations:
  - Fever
  - Rigors
  - Tachycardia
  - Headache
Chronic (nodular) lymphangitis:
- Erythematous nodule, chancriform ulcer, or wart-like lesion develops in SC tissue at inoculation site
- Often presents without pain or evidence of systemic infection
- Multiple lesions possible along lymphatic chain

History
History and physical exam directed at discovering source of infection
Physical Exam

Fever
Erythematous streaks from source of infection proceeding toward regional lymph nodes

Essential Workup

Lymphangitis is a clinical diagnosis

Diagnosis Tests & Interpretation

Lab

WBC is unnecessary but often elevated
Gram stain and culture of initial lesion to focus antimicrobial selection and reveal resistant pathogens (MRSA):
- Aspirate point of maximal inflammation or punch biopsy
- Essential if treatment failure
If sporotrichosis or M. marinum infection is suspected, diagnosis should be confirmed by culture of organism from wound
Blood culture may reveal organism

Imaging

Imaging is not commonly performed
Plain radiographs may reveal abscess formation, SC gas, or foreign bodies if these are suspected
Extremity vascular imaging (doppler US) can help rule out deep venous thrombosis

Differential Diagnosis

Thrombophlebitis; deep venous and superficial:
- Differentiation from lymphangitis:
  - Absence of initial traumatic or infectious focus
  - No regional lymphadenopathy
IV line infiltration
Smallpox vaccination, normal variant of usual reaction to vaccination
Phytophotodermatitis:
- Linear inflammatory reaction, mimics lymphangitis
- Lime rind, lime juice, and certain plants can act as photosensitizing agents

Treatment

Initial Stabilization/Therapy

If patient is septic, manage airway and resuscitate as indicated

Ed Treatment/Procedures

Antimicrobial therapy should be initiated with first dose in ED
General principles:
- Consider local prevalence of MRSA and other resistant pathogens in addition to usual causes
- Usual outpatient treatment: 7 " 10 days
- Elevation
- Application of moist heat
Acute lymphangitis, empiric coverage:
- Outpatient:
  - Oral cephalexin plus trimethoprim/sulfamethoxazole (TMP/SMX) (to cover CA-MRSA)
  - Alternatives to cephalexin: Oral dicloxacillin, macrolide, or levofloxacin
  - Alternatives to TMP/SMX: Clindamycin or doxycycline
Inpatient: IV nafcillin or equivalent
Lymphangitis after dog or cat bite: IV ampicillin/sulbactam
MRSA:
- Nosocomial MRSA: IV vancomycin or PO or IV linezolid
- CA-MRSA:
  - PO: TMP/SMX, clindamycin, or doxycycline
  - IV: Vancomycin or clindamycin
Sporotrichosis:
- Itraconazole or saturated solution of potassium iodide (SSKI)
M. marinum:
- Localized granulomas are usually excised
- Antimicrobial therapy is usually reserved for more severe infections:
  - Limited data on what combination of agents should be used
  - Rifampin and ethambutol may be best choice

Medication

Ampicillin/sulbactam: 1.5 " 3 g (peds: 100 " 300 mg/kg/24 h up to 40 kg; >40 kg, give adult dose) IV q6h
Cephalexin: 500 mg (peds: 50 " 100 mg/kg/24 h) PO QID
Clindamycin: 450 " 900 mg (peds: 20 " 40 mg/kg/24h) PO or IV q6h
Dicloxacillin: 125 " 500 mg (peds: 12.5 " 25 mg/kg/24h) PO q6h
Doxycycline: 100 mg PO BID for adults
Erythromycin base: (Adult) 250 " 500 mg PO QID
Itraconazole (adult): 200 mg PO daily, continue until 2 " 4 wk after all lesions resolve (usually 3 " 6 mo); peds: Not approved for use
Levofloxacin: (Adult only) 500 " 750 mg PO or IV daily
Linezolid: 600 mg PO or IV q12h (peds: 30 mg/kg/24 h div. q8h)
Nafcillin: 1 " 2 g IV q4h (peds: 50 " 100 mg/kg/24 h div. q6h); max. 12 g/24 h
Rifampin: 600 mg PO BID for adults
TMP/SMX: 2 DS tabs PO q12h (peds: 6 " 10 mg/kg/24 h TMP div. q12h)
Vancomycin: 1 g IV q12h (peds: 10 mg/kg IV q6h, dosing adjustments required for age <5 yr); check serum levels

Follow-Up

Disposition

Admission Criteria

Toxic appearing
History of immune suppression
Concurrent chronic medical illnesses
Unable to take oral medications
Unreliable patients

Discharge Criteria

Mild infection in a nontoxic-appearing patient
Able to take oral antibiotics
No history of immune suppression or concurrent medical problems
Adequate follow-up within 24 " 48 hr

Follow-Up Recommendations

Follow-up within 24 " 48 hr
Sooner if worsening symptoms, including worsening fever or other systemic symptoms
Outline the border of erythema before discharge to aid in assessing response to therapy

Pearls and Pitfalls

Empiric antibiotic coverage must extend to include CA-MRSA, in addition to coverage for other staph species and strep.

Additional Reading

Pasternack MS, Swartz MN. Lymphadenitis and lymphangitis. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas and Bennetts Principles and Practice of Infectious Diseases. 7th ed. New York, NY: Elsevier/Churchill Livingstone; 2010:1323 " 1334.
Rex JH, Okhuysen PC. Sporothrix schenckii. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 7th ed. New York, NY: Elsevier/Churchill Livingstone; 2010:3271 " 3276.
Smego RA, Castiglia M, Asperilla MO. Lymphocutaneous syndrome: A review of nonsporothrix causes. Medicine (Baltimore). 1999;78:38 " 63.

Codes

ICD9

041.12 Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site
457.2 Lymphangitis
682.9 Cellulitis and abscess of unspecified sites

ICD10

A49.02 Methicillin resis staph infection, unsp site
I89.1 Lymphangitis
L03.91 Acute lymphangitis, unspecified
L03.90 Cellulitis, unspecified

SNOMED

1415005 Lymphangitis (disorder)
8838005 Acute lymphangitis (disorder)
12713001 cellulitis of skin with lymphangitis (disorder)
266096002 methicillin resistant Staphylococcus aureus infection (disorder)

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