Author:
JohnMahoney
DoloresGonthier
Description
- Lymphangitis is the infection of lymphatics that drain a focus of inflammation or other infection
- Histologically, lymphatic vessels are dilated and filled with lymphocytes and histiocytes
Etiology
- Acute lymphangitis:
- Caused by bacterial infection
- Most common: Group A β-hemolytic Streptococcus
- Less common: Other strep species, methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant S. aureus (MRSA):
- Risk factors for Staph infection (MSSA and MRSA):
- Recent hospital or long-term care admission
- Recent surgery
- Children
- Soldiers
- Incarcerated persons
- Athletes in contact sport
- Injection drug use
- Men who have sex with men
- Dialysis treatments and catheters
- History of penetrating trauma
- Additional risk factors for MRSA infection:
- Prior MRSA infection
- MRSA colonization
- Area of high MRSA incidence
- Close contact with MRSA patient
- Other organisms:
- Pasteurella multocida (cat or dog bite)
- Streptobacillus moniliformis (rat-bite fever)
- Wuchereria bancrofti (filariasis): Mosquito borne
- Consider in immigrants from Africa, Southeast Asia/Pacific, and tropical South America with lower-extremity involvement
- Chronic (nodular) lymphangitis:
- Usually caused by mycotic, mycobacterial, and filarial infections
- Sporothrix schenckii (most common cause of chronic lymphangitis in the U.S.):
- 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
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
- Identify occupations and geographic and environmental exposures that may point to etiology
- Discover source of infection
- Explore duration and recurrence of symptoms
- If Staph etiology: Progression of disease is more indolent, associated with trauma
- If Strep etiology: More acute onset
Physical Exam
- Fever, other systemic signs
- Identify source of infection
- Look for erythematous streaks or nodules from source of infection proceeding toward regional lymph nodes
- If Staph etiology: Source more likely to have pustular component
Essential Workup
Lymphangitis is a clinical diagnosis
Diagnostic Tests & Interpretation
Lab
- WBC is unnecessary but often elevated
- Culture wound or aspirate if:
- Pustular collection present
- Suspect an unusual or resistant pathogen
- Initial therapy is not successful
- Tissue biopsy may be helpful for identifying a specific etiology
- If sporotrichosis or M. marinum infection is suspected, diagnosis should be confirmed by culture of organism from wound
- Blood culture may reveal organism
- Filariasis can be diagnosed using a blood smear (thick, nocturnal) or serologic techniques
Imaging
- Ultrasound useful for diagnosing abscess if physical exam is equivocal or if there is a broad area of cellulitis
- Extremity vascular imaging (Doppler ultrasound) can help rule out deep venous thrombosis
- Plain radiographs may reveal abscess formation, SC gas, or foreign bodies if these are suspected
Differential Diagnosis
- Thrombophlebitis; deep venous and superficial:
- Differentiation from lymphangitis:
- Absence of initial traumatic or infectious focus
- No regional lymphadenopathy
- IV line infiltration
- 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
Initial Stabilization/Therapy
If patient is septic, manage airway and resuscitate as indicated
ED Treatment/Procedures
- Antimicrobial therapy should be initiated with 1st dose in ED
- General treatments:
- Extremity elevation
- Analgesics
- Application of moist heat
- General principles:
- Aggressive treatment is recommended if considering group A β-hemolytic Streptococcus as the etiology, because disease progression can be rapid
- Consider local prevalence of MRSA and other resistant pathogens in addition to usual causes
- Usual outpatient treatment: 7-10 d
- Follow-up in 48-72 hr to assess improvement
- If there is suspicion that Staph could be a causative agent, antibiotics should cover both MSSA and MRSA
- This suspicion should be based on the clinical exam, history, and assessment of risk factors
- Acute lymphangitis, empiric coverage:
- Outpatient:
- Inpatient:
- IV nafcillin or IV cefazolin
- Alternative: IV clindamycin
- MRSA treatment: Add the following if suspicion that MRSA is etiologic agent
- Outpatient:
- TMP/SMX
- Alternative: Doxycycline
- Inpatient:
- IV vancomycin
- Alternative: IV linezolid
- Lymphangitis after dog or cat bite:
- Sporotrichosis:
- M. marinum:
- Localized granulomas are usually excised
- Antimicrobial therapy is usually reserved for more severe infections:
- Limited data on what agent(s) should be used
Medication
- Ampicillin/sulbactam: 1.5-3 g (peds: 100-300 mg/kg/24 hr up to 40 kg; >40 kg, give adult dose) IV q6h
- Cefazolin: 1-1.5 g (peds: 50-100 mg/kg/24 hr; max. 6 g/24 hr) IV q8h
- Cephalexin: 500 mg (peds: 25-50 mg/kg/24 hr; max. 4 g/24h) PO QID
- Clindamycin: 300-450 mg (peds: 30-40 mg/kg/24 hr) PO q6h; 600 mg (peds: 25-40 mg/kg/24 hr) IV q8h
- Dicloxacillin: 250-500 mg (peds: 12.5-25 mg/kg/24 hr) PO q6h
- Doxycycline: 100 mg PO b.i.d for adults
- Itraconazole (adult): 200 mg PO daily, continue until 2-4 wk after all lesions resolve (usually 3-6 mo); peds (3-5 mg/kg/24 hr PO q12h)
ALERT |
| Significant drug interactions. Pregnancy category C. |
- Linezolid: 600 mg PO or IV q12h (peds <12 yo: 30 mg/kg/24 hr PO or IV q8-12h)
- Nafcillin: 1-2 g IV q4h (peds: 100-200 mg/kg/24 hr IV q6h); max. 12 g/24 hr
- Trimethroprim/sulfamethoxazole (TMP/SMX) 1-2 DS tabs (peds: 8-12 mg/kg/24 hr based on TMP component) PO q12h
- Vancomycin: 30-40 mg/kg/24 hr IV q 8-12h, do not exceed 4 g/24 hr or 2 g/dose (peds: 40 mg/kg/24 hr IV q6h; dosing adjustments required younger than age 5 yr); check serum levels
Disposition
Admission Criteria
- Toxic appearing
- Signs of systemic illness
- History of immune suppression
- Concurrent chronic medical illnesses
- Unable to take oral medications
- Unreliable patients
- Outpatient treatment failure
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
- KauffmanCA, BustamanteB, ChapmanSW, et al. Clinical practice guidelines for the management of sporotrichosis: 2007 update by the Infectious Diseases Society of America . Clin Infect Dis. 2007;45:1255-1265.
- NubileMJ. Nodular lymphangitis: A distinctive clinical entity with finite etiologies . Curr Infect Dis Rep. 2008;10:404-410.
- PasternackMS, SwartzMN. Lymphadenitis and lymphangitis. In: BennettJE, DolinR, BlaserMJ, eds. Mand ell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 8th ed.New York: Elsevier/Churchill Livingstone; 2014:1226-1237.
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