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:
- 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
[Outline]
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:
- 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:
- 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
[Outline]
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
[Outline]
Empiric antibiotic coverage must extend to include CA-MRSA, in addition to coverage for other staph species and strep.
- Pasternack MS, Swartz MN. Lymphadenitis and lymphangitis. 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; 2010:1323–1334.
- 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.
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