Lymphangitis– Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

  • Local inflammation of lymphatic vessels; can be acute or chronic
  • Usually due to trauma and/or infection of the nearby skin

Risk Factors

  • Diabetes mellitus
  • Chronic steroid use
  • Prolonged time with a peripheral venous catheter in place
  • Varicella infection
  • Immunocompromise
  • Human, animal, or insect bites
  • Fungal skin infections
  • Any trauma to the skin

General Prevention

Proper wound care (1)[A]

Etiology

  • Acute or chronic infection of the skin causing inflammation of lymphatic channels
  • Acute infection:
    • Usually caused by Streptococcus pyogenes
    • Uncommonly caused by:
      • Staphylococcus aureus
      • Pasteurella multocida
      • Spirillum minus (rat-bite disease)
      • Pseudomonas
      • Other Streptococcus sp.
  • Chronic infection: Caused by parasites (filariasis) or fungi (sporotrichosis)
  • Immunocompromised patients can be infected with gram-negative rods, gram-negative bacilli, or fungi.
  • In freshwater, think Aeromonas hydrophila.
  • Worldwide, Wuchereria bancrofti is most common causative agent.

Commonly Associated Conditions

  • Lymphedema
  • Lymph node dissection
  • Athlete’s foot
  • Sporotrichosis
  • Cellulitis
  • Erysipelas (often coexists)
  • Filarial infection

Infection, Allergy, staphylococcus aureus, fever and chills, nearby skin, loss of appetite, gram negative rods, acute infection,

Diagnosis

  • Local symptoms:
    • Red macular linear streaks from site of infection toward the regional draining lymph node
    • Tenderness and warmth over affected skin
    • May have lymph node involvement
    • May have blistering of affected skin
  • Systemic symptoms:
    • Malaise
    • Fever and chills
    • Loss of appetite
    • Headache
    • Muscle aches

History

History of trauma to skin, cut, abrasion, or fungal infection (e.g., athlete’s foot)

Physical Exam

  • Look for abscess.
  • May have lymph node tenderness

Diagnostic Tests & Interpretation

Lab

  • Complete blood count (CBC) may show leukocytosis.
  • Blood cultures

Imaging

Plain radiology unnecessary

Diagnostic Procedures/Surgery

  • Aspirate and culture any pus.
  • Use sensitivity to guide antibiotic treatment.

Differential Diagnosis

  • Septic thrombophlebitis (2)[C]
  • Superficial thrombophlebitis (2)[C]: Feel for induration over the vein.
  • Contact dermatitis (2)[C]
  • Allergic reaction (2)[C]: Less likely to be allergic if >24 h after exposure (e.g., insect bite)

Treatment

Antifilarial medication does not help the lymphangitis associated with filariasis (1)[A].

Medication

  • If nontoxic and >3 years of age, treat as an outpatient with oral antibiotics.
  • If no improvement after 48 h of oral antibiotics, change to IV antibiotics.
  • If systemic involvement, start IV antibiotics immediately.
  • If group A hemolytic Streptococcus is suspected, treat aggressively.

First Line

  • Antibiotics (1)[A]:
    • Dicloxacillin:
      • Adults: 500 mg p.o. q6h
      • Children: 50 mg/kg/d divided into q.i.d. dosing
    • Nafcillin:
      • Adults: 2 g IV q4h
      • Children: 150 mg/kg/d divided into q.i.d. dosing
    • Cephalexin:
      • Adults: 500 mg p.o. q6h
      • Children: 50 mg/kg/d p.o. divided into q.i.d. dosing
    • Clindamycin (if penicillin or cephalosporin allergy):
      • Adults: 150–300 mg p.o. q6–8h or 600 mg IV q8h
      • Children: 8–20 mg/kg/d p.o. divided into t.i.d. or q.i.d. dosing; 20–40 mg/kg/d IV/IM divided into t.i.d. or q.i.d. dosing
  • Acetaminophen or ibuprofen for pain and fever

Second Line

Trimethoprim-sulfamethoxazole (TMP-SMZ) good for areas with high rates of methicillin-resistant S. aureus [MRSA]):

  • Adults: 160 mg TMP/800 SMZ mg p.o. q12h × 10–14 days
  • Children >2 months of age: 10–20 mg/kg/d p.o. or IM divided into t.i.d. or q.i.d. doses × 14 days

Additional Treatment

General Measures

  • Hot, moist compresses to affected area
  • If lymphedema is involved, compression garments and weight loss may help.

Surgery/Other Procedures

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Incision and drainage of abscessed areas

In-Patient Considerations

Initial Stabilization

  • ABCs
  • Fluids if in hypotensive shock

Admission Criteria

  • If patient requires IV antibiotic therapy
  • If symptoms are severe (3,4)[C]:
    • High fever
    • Rigor
    • Systemic toxicity
    • Shock
  • Altered mental status

Discharge Criteria

Patient can be discharged on oral antibiotics once systemic symptoms resolve.

Ongoing Care

Follow-Up Recommendations

  • Elevate affected area when at rest, if possible (3)[C].
  • 48-h follow-up to ensure proper antibiotic coverage (if outpatient)

Patient Monitoring

Close follow-up to ensure decreasing inflammation

Patient Education

Instruct patients on proper wound care (and foot care, if applicable).

Prognosis

  • Good prognosis for uncomplicated lymphangitis
  • Antimicrobial therapy is effective in 90% of patients.
  • Untreated, can spread rapidly, especially group A Streptococcus

Complications

  • Sepsis
  • Bacteremia
  • Cellulitis extending from vessels

References

1. Badger C, Preston N, Seers K, et al. Antibiotics/Anti-inflammatories for reducing acute inflammatory episodes in lymphoedema of the limbs (Cochrane Review). In: The Cochrane Library. Oxford: Update Software; 2006;1.

2. Falagas ME, Bliziotis IA, Kapaskelis AM. Red streaks on the leg. Am Fam Phys. 2006;73(6):1061–2.

3. Bonnetblanc JM, Bédane C. Erysipelas: recognition and management. Am J Clin Dermatol. 2003;4:157–63.

4. Edlich RF, Winters KL, Britt LD. Bacterial diseases of the skin. J Long-Term Effects Med Implants. 2005;15(5):499–510.

Additional Reading

Haddad FG, Waked CH, Zein EF. Peripheral venous catheter-related inflammation. A randomized prospective trial. J Med Liban. 2006;54:139–45.

Pereira de Godoy JM, Azoubel LM, Guerreiro Godoy Mde F et al. Erysipelas and lymphangitis in patients undergoing lymphedema treatment after breast-cancer therapy. Acta Dermatovenerol Alp Panonica Adriat. 2009;18:63–5.

Codes

ICD9

457.2 Lymphangitis

Snomed

1415005 lymphangitis (disorder)

Clinical Pearls

  • The classic presentation of lymphangitis is red, linear streaks along the skin from an infected site (e.g., bite, cut, abrasion) to the draining lymph node for that region.
  • Patients who have lymph node dissection as part of their breast cancer treatment may have difficulty draining lymphatic fluid properly, leading to lymphedema and an increased predisposition to infection and lymphangitis.
  • A patient with severe systemic symptoms (e.g., high fever, rigors, shock, septic, altered mental status) should be admitted and treated with IV antibiotics. A patient with moderate systemic symptoms (e.g., fever, chills, muscle aches) should be monitored closely for worsening but could be treated as an outpatient.
  • Patients can take ibuprofen or acetaminophen for the pain and/or fever associated with lymphangitis. Ibuprofen also helps with inflammation at high doses.
  • Usually parasitic or fungal infections cause chronic lymphangitis.

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