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Lymphangitis, Emergency Medicine

Basics

Description

- 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

- 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

- 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

- 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

- 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

  • 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 infectionMost commonly group A ²-hemolytic StreptococcusLess 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 menDifferent antibiotic susceptibility than nosocomial MRSACA-MRSA now sufficiently prevalent to warrant empiric treatmentSuspect CA-MRSA in unresponsive infections or if multiple or recurrent abscessesOther 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 infectionsSporothrix 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 mossMultiple SC nodules appear along course of lymphatic vesselsTypical antibiotics and local treatment fail to cure lesionMycobacterium marinum:Atypical MycobacteriumGrows optimally at 25 " 32 °C in fish tanks and swimming poolsMay produce a chronic nodular, single wart-like or ulcerative lesion at site of abrasionAdditional lesions may appear in distribution similar to sporotrichosisNocardia brasiliensisMycobacterium kansasiiW. bancrofti

Diagnosis

Signs and Symptoms

  • Acute lymphangitis:Warm, tender erythematous streaks develop and extend proximally from the source of infectionRegional lymph nodes often become enlarged and tender (lymphadenitis).Peripheral edema of involved extremitySystemic manifestations:FeverRigorsTachycardiaHeadache
  • Chronic (nodular) lymphangitis:Erythematous nodule, chancriform ulcer, or wart-like lesion develops in SC tissue at inoculation siteOften presents without pain or evidence of systemic infectionMultiple 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 biopsyEssential 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 focusNo regional lymphadenopathy
  • IV line infiltration
  • Smallpox vaccination, normal variant of usual reaction to vaccination
  • Phytophotodermatitis:Linear inflammatory reaction, mimics lymphangitisLime 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 causesUsual outpatient treatment: 7 " 10 daysElevationApplication 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 levofloxacinAlternatives 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 linezolidCA-MRSA:PO: TMP/SMX, clindamycin, or doxycyclineIV: Vancomycin or clindamycin
  • Sporotrichosis:Itraconazole or saturated solution of potassium iodide (SSKI)
  • M. marinum:Localized granulomas are usually excisedAntimicrobial therapy is usually reserved for more severe infections:Limited data on what combination of agents should be usedRifampin 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.

See Also (Topic, Algorithm, Electronic Media Element)

  • Cellulitis
  • Lymphadenitis
  • MRSA

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)