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AlexanderSalava

Lymphangitis

There is usually an underlying acute skin infection with inflammation spreading in the superficial layers of the skin and additionally through lymphatic vessels (erysipelas, for example).
The main sign of an acute skin infection is linear erythema along the lymphatic vessels. Diagnosis is based on the clinical picture and elevated inflammatory markers.
The rare nodular lymphangitis can be seen in sporotrichosis, atypical mycobacterial skin infections and some infections endemic to warm climates (e.g. filariasis).
Noninfectious causes include malignant tumours metastasizing in lymphatic vessels.

In lymphangitis associated with acute skin infections, there is lymphangitic streaking, i.e. acute-onset, clearly defined, hot erythema spreading in the direction of local lymph nodes.
In addition, the skin is often swollen and lymph nodes are tender. There may be blisters and ulcers.
The patient may have fever and general symptoms. The clinical picture may be septic.
Inflammatory markers are usually elevated.
Location: most commonly on the limbs, more rarely on the face, in the genital area or on the trunk.
Symptoms are often preceded by injury or minor skin trauma (wound, broken skin, bite, etc.).

Irregularly distributed single erythematous nodules and/or wounds can be seen in the area of the lymphatic system.
Domestic cases may, depending on the country e.g. in Europe, be due to sporotrichosis, tularaemia or an atypical mycobacterial skin infection. The disease may also be caused by an agent contracted in an endemic area (immigrants and tourists; see below).

There is spontaneous erythematous streaking on the skin. The clinical picture is similar to that of skin infections but inflammatory and general symptoms are usually missing.
In lymphangitis due to cancer, the changes are usually in the tumour area, along the local lymphatic vessels.

Most common causes
- Erysipelas (group A streptococcus) Erysipelas
- Cellulitis (may be a mixed infection, usually including Staphylococcus aureus)
- Abscess Skin Abscess and Folliculitis or wound infection, may be posttraumatic (usually Staphylococcus aureus)
Less common causes
- Gram-negative bacteria (particularly in patients with diabetes or immunosuppression) Treatment of the Diabetic Foot
- Pasteurella bacteria (in animal bites, by a cat or dog, for example) Bite Wounds
- Herpes simplex (primary infection or severe reactivation) Herpes Simplex Infection of the Skin
- Insect stings (severe local reaction to Hymenoptera, for example) Insect Stings and Bites
- Skin infections caused by Aeromonas bacteria (wound infection from fresh water).
- Tularaemia (ulceroglandular tularaemia; may also cause nodular lymphangitis) Tularaemia (picture 1)

Sporotrichosis (deep fungal infection, often beginning on broken skin in gardeners, for example) Skin Problems in Returning Travellers
Atypical mycobacteria (e.g. Mycobacterium marinum; fish tank granuloma, tender nodules on hands and arms developing on broken skin in contact with water, for example) Skin Problems in Returning Travellers
Filariasis (Wuchereria worms, for example; recurrent lymphangitis with fever, in tropical regions) Filariases
Cutaneous nocardiosis (Nocardia bacteria; abscess-like lesions usually first on broken skin, from endemic regions)
Cutaneous leishmaniasis (from endemic regions) Leishmaniases
Deep fungal infections (e.g. mycetoma, chromoblastomycosis, from endemic regions) Deep Endemic Mycoses

CRP, basic blood count with platelet count; may be normal at the onset of an acute skin infection, rise in leucocyte count usually takes place first.
From febrile or very ill patients, blood cultures
Bacterial culture from any skin wound or portal of entry for infection, as necessary
If rarer infections are suspected, take targeted microbiological samples, such as samples for herpes (swab from the base of a blister) or tularaemia (paired sera)
In nodular or noninfectious lymphangitis, skin biopsy and targeted microbiological investigations of the biopsy sample, as necessary
- Sporotrichosis: histology of skin biopsy (fungal staining), fungal culture and PCR assays
- Atypical mycobacteriosis: histology of skin biopsy (mycobacterial staining), mycobacterial culture (showing atypical mycobacteria) and PCR assay (to exclude M. tuberculosis infection)
In noninfectious lymphangitis, imaging may be necessary (malignancies).

Septic thrombophlebitis (intravenous catheters, punctures, for example)
Shingles before the blistering stage (pain before skin lesions, tender to touch) Shingles (Herpes Zoster)

Superficial thrombophlebitis and deep vein thrombosis (immobilization, risk factors) Deep Vein Thrombosis Superficial Thrombophlebitis (Ultrasonography)
Acute allergic contact dermatitis (eczema with itching as the main symptom) Allergic Contact Dermatitis
Gout and pseudogout (erythema first in joint region) Gout and Pseudogout

If there is an acute skin infection, its cause should be treated Erysipelas Skin Abscess and Folliculitis Bite Wounds Severe Infections of the Skin and Soft Tissues.
- A limb with lymphangitis should be immobilized.
Nodular lymphangitis should be treated according to its cause; a microbiological diagnosis and consulting specialized care are usually necessary.
- Long courses of antimicrobial treatment and surgical excision are used for treatment.
Noninfectious lymphangitis requires causative treatment.

For severe skin infections and high-risk patients (with diabetes or immunosuppression, for example) emergency hospital treatment is necessary; for infections caused by resistant microbes (e.g. MRSA) Multidrug-Resistant Bacteria in Hospitals, consult an infectious diseases specialist, as necessary.
Emergency surgical assessment is indicated if a necrotizing infection is suspected.
For the rare nodular lymphangitis, consult a skin or infectious diseases specialist.

Russo A, Concia E, Cristini F et al. Current and future trends in antibiotic therapy of acute bacterial skin and skin-structure infections. Clin Microbiol Infect 2016;22 Suppl 2():S27-36. [PubMed]
Raff AB, Kroshinsky D. Cellulitis: A Review. JAMA 2016;316(3):325-37. [PubMed]
Kwak YG, Choi SH, Kim T et al. Clinical Guidelines for the Antibiotic Treatment for Community-Acquired Skin and Soft Tissue Infection. Infect Chemother 2017;49(4):301-325. [PubMed]
Cohen BE, Nagler AR, Pomeranz MK. Nonbacterial Causes of Lymphangitis with Streaking. J Am Board Fam Med 2016;29(6):808-812. [PubMed]
van Bijnen EM, Paget WJ, den Heijer CD et al. Primary care treatment guidelines for skin infections in Europe: congruence with antimicrobial resistance found in commensal Staphylococcus aureus in the community. BMC Fam Pract 2014;15():175. [PubMed]
Faccini-Martínez ÁA, Zanotti RL, Moraes MS et al. Nodular Lymphangitis Syndrome. Am J Trop Med Hyg 2017;97(5):1282-1284. [PubMed]