Friday, February 24, 2012

Nodular lymphangitis: Report of a case with presentation of a diagnostic paradigm.

Nodular lymphangitis: Report of a case with presentation of a diagnostic paradigm.

Sept 2010

Giordano CN, Kalb RE, Brass C, Lin L, Helm TN.


University at Buffalo School of Medicine and Biomedical Sciences, USA.


A 54-year-old man with asthma, mitral valve prolapse, and a back injury developed erythematous nodules that progressed along the lymphatic drainage of his right arm. Skin biopsy revealed granulomatous inflammation with microabscess formation. Culture confirmed Mycobacterium marinum infection.

The patient was treated with clarithromycin, ethambutol, rifampin, and topical silver sulfadiazine. Oral doxycycline hyclate was later added because of slow healing. Mycobacterium marinum is one of a group of infectious agents that can cause nodular lymphangitis. Sporotrichoid lesions most commonly develop after cutaneous inoculation with Sporothrix schenckii, Leishmania species, Nocardia species, and Mycobacterium marinum.

A thorough clinical history and physical examination can narrow the differential diagnosis by eliciting information about the etiologic setting, incubation time, clinical appearance of the lesions, and presence or absence of systemic involvement for each of the causative organisms. Skin biopsy and microbiological tissue cultures are essential for diagnostic confirmation. The differential diagnosis and a suggested diagnostic paradigm will be reviewed.

Dermatology Online Journal



Discussion Lymphangitis

Often confused with and called cellulitis; lymphangitis is an inflammation or infection of the lymphatic channels from an infection beginning elsewhere in the body. Due to the immuncompromised limb,lymphedema patients are quite susceptible to this infection.


Most commonly lymphangitis is caused either by the group A beta-hemolytic streptococcal bacteria or by Staph Aureus. Other bacterial causes include Pseudomonas, Aeromonas hydrophila, in the filarial regions lymphangitis is often caused by Wuchereria bancrofti.

Invasive bacteria enter throught a cut, scratch, insect bite, surgical wound or other skin injury.


Symptoms include red streaks extending from the primary infection sites through the affected area. These streaks may be painful and tender. Note tjat this is different then the “patches” or “splotches” of tend red areas associated with generalized cellulitis.

  • If the infection is in an arm or leg, you may have generalized limb swelling.

    Lymph nodes are usually swollen and painful.

    These symptoms may be accompanied by fever, chills, rapid hear rate and headache.

    red streaks from infected area to the armpit or groin

    may be faint or obvious

    throbbing pain along the affected area (common)

    may involve the lymph nodes (see above)

    fever of 100 to 104 degrees Fahrenheit and/or chills

    individuals may have a general ill feeling (malaise), with loss of appetite, headache, and muscle aches


Diagnoses is generally achieved through the symptoms. An examination shows affected lymph nodes and/or lymph vessels and may indicate the cause.

A blood test also may be done to determine the exact pathogen, and or to determine if the bacterium has actually entered the bloodstream. Blood cultures may also reveal spread of infection to the bloodstream.

Risk Factors

Patients with any of the following disorders are more at risk for developing serious and or life threatening lymphangitis


Diabetes, immunodeficiency (of any type), Varicella (cellulitis as a complication of), chemotherapy patients, venous insufficiency or venous stasis, chronic steroid users, post surgical patients, individuals with edema and finally age may also be a factor with infants and the elderly more susceptible to infections.


Can include bacteremia, septicemia, tissue necrosis, gangrene, amputation of the affected limb, death. It should be noted also that lymphangitis causes further damage to the lymphatics and thereby makes lymphedema worse. Other complications include skin abcesses.

In compromised patients, physicians must be careful to observe for a complicating gram-negative super infection that can accompany regular gram-positive bacteria. This can occur asa result of the even further depletion of the body's immune system.

Complications may also include:

  • abscess formation
  • cellulitis
  • sepsis (generalized or bloodstream infection)
  • fistula formation (seen with lymphadenitis due to tuberculosis)


Immediate treatment with appropriate antibiotics is the accepted therapy. These antibiotics can include Dicloxacillin, Cephlalexin (Keflex), Nafcillin; Bactrim; Augmentin, oxacillin.

IV antibiotics:

can include Unasyn, Gentamicin, Vancomycin.

In addition to the antibiotics, pain medication and anti-inflammatory medicines may be prescribed.


With early diagnosis and subsequent rapid treatment the outcome is actually excellent with the overwhelming number of patients making full recovery. In special risk groups however, there is a heightened risk of complication and morbidity.

It should also be noted that the medical literature reports secondary lymphedema can be and is caused by infections, including lymphangitis.

Related Keywords

lymphangitis, lymphangeitis, lymphangiitis, lymphatic system, inflammation of the lymphatic channels, bacteremia, cellulitis, septic thrombophlebitis, superficial thrombophlebitis, necrotizing necrotizing fasciitis, myositis, sporotrichosis


Wednesday, February 22, 2012



This is by far and wide, the most common infection lymphedema patients experience.

Discussion Acute Cellulitis

Acute Cellulitis is one of the complications of lymphedema. The patient may not be aware of the source of the etiology. Sometimes it may be a cut, mosquito bite, open wound or other infection in the body.

The first sign is increased or different quality of PAIN involving the lymphedema limb. The patients often describe this as a "flu like symptom or an ache" involving the Lymphedema arm or leg. This is usually followed by sudden onset of ERYTHEMA (redness, red streaks or blotches) on the involved limb. The HYPERTHERMIA (lymphedema limb becomes warm, hot) will follow and the patient may experience the CHILLS and even HIGH FEVER.

The early intervention and treatment with antibiotics will resolve this condition (it usually takes a very minimum ten day course of antibiotics). Only a Medical Doctor will be able to prescribe the Antibiotics, thus a consultation with a Doctor is necessary. Severe Cellulitis may require Intravenous Antibiotic treatment and hospitalization. Again, elevation of the affected limb is important.

During that phase the patient should NOT massage the lymphedema limb, bandage, apply the pump, wear tight elastic sleeve or exercise excessively. Avoid the blood pressure and blood to be drawn from the involved arm. Keep the limb elevated as much as possible while resting. Once the symptoms dissipate the treatment MLD/CDP should be initiated.

How do we prevent this infection? The patient should be careful with daily activities and take all precautions to protect the skin (wear gloves when gardening, cleaning with detergents, etc... ). If an injury to skin occurs on the lymphedema limb it is necessary to clean the wound with alcohol or hydrogen peroxide and apply Neosporin/Polysporin antibiotic ointment. If the symptoms progress seek the attention of a physician immediately.

It is so very important to avoid getting cellulitus as it further destroys the lymphatic system. Allowed to spread or continue it can become systemic and can lead to gangrene, amputation of the limb or even death.

Risk Factors

Cracks or peeling skin between the toes

History of peripheral vascular disease

Injury or trauma with a break in the skin (skin wounds)

Insect bites and stings animal bites, or human bites

Ulcers from certain diseases, including diabetes and

vascular disease

Use of corticosteroid medications or

medications that suppress the immune system

Wound from a recent surgery



Cellulitis is clinically a spreading infection involving both the dermis and subcutaneous tissues. Unlike erysipelas, it will not have a clear raised border. Other features may include red streaking from the infected area, regional lymphadenopathy.


The basic way of diagnosing cellulitis is through a physical exam of the effected area, inconjunction with the above symptoms. Rememer, the area may be very red, warm to the touch, swollen and painful.

The doctor will also look for any cuts, scrapes, bites, ulcers or bruises, each is where bacteria could have entered the body.

Additional tests such as a blood test or culture may also be needed to determine the type of bacteria causing the infection.


Symptoms include all over body ache, fever, severe pain of the infected area, chills, weakness. The skin color will be red, warm and very tender to the touch.


The most common bacteria responsible for cellulitis infections are staph aureus and strep A. Other less common bacterial agents include Strep B, gram-negative bacteria, and immunocompromised patients pneumococcus. Less common bacteria such as Hemophilus influenzae, Pasturella multocide, and erysipelothrix rhusiopathiae can cause it as well.

Entry foci for the bacteria includes nasal cavities, wound, cuts, scrapes (any type of skin break). Insect bites (especially spider) can cause the condition. Cat scratches, animal bites are another source of bacteria.


Cellulitis responds well to antibiotic therapy. Generally, a ten day course of treatment is prescribed. Antibiotics used to treat cellulitis include Keflex, Augmentin, penicillins. Unasyn and vancomycin are standard IV antibiotics. In situations of a gram negative infection, Gentamicin is used. The types of antibiotic treatments include oral, topical (for a wound or skin cut) and intravenous antibiotics. Often it is only the IV antibiotic that can actually penetrate the fibrotic lympedema tissue to reach the bacteria.

For special at risk patients, blood work may also be indicated to assure the infection has not become systemic.

This group, which includes lymphedema patients may need extended IV antibiotic therapy. Lymphedema patients also need to elevate the effected limb, stop using compression garments and/or bandages until the infection has cleared.

See also: Lymphedema and Cellulitis

ICD9 - ICD10 - Related Resource Information

ICD-10L03. -
ICD-92008 ICD-9-CM Diagnosis 682.9

Cellulitis and abscess of unspecified sites

  • 682.9 is a specific code that can be used to specify a diagnosis
  • 682.9 contains 27 index entries
  • View the ICD-9-CM Volume 1 682.* hierarchy

682.9 also known as:

  • Abscess NOS
  • Cellulitis NOS
  • Lymphangitis, acute NOS

682.9 excludes:

eMedicinemed/310 emerg/88 derm/464

Tuesday, February 14, 2012

Lymphedema infections

I feel it is important to have an understanding of the various types of infections that we face with lymphedema. These infections include cellulitis, lymphangitis, and erysipelas. An extensive list follows below.
One must remember that every infection we have further damages our lymphatics, thus leading to more severe lymphedema. Untreated infection will lead to sepsis (commonly refered to as blood poisoning), gangrene which involves loss of limb and/or eventual death.
In treating any type of infection, the doctor not only must identify the type of bacteria involved, but must understand the staging of lymphedema and the differences in the tissue types of the stages.
Heavily fibrotic lymphedema limbs are exceedingly difficult to treat because the denseness of the tissue impeeds or even can prevent the chosen antibiotic from reaching the bacteria. In this situation long term IV antibiotic thereapy should be considered.
I will be doing posts on all the related infections. We need to remember (as does the doctor), that a limb with lymphedema is a localized immunosuppressed area, which means in practical terms that any infection has the potential of agressive spread and can quickly become life threatening.
The most common bacterial infections that lymphedema patients have difficulties with includes:
Necrotizing Fascilitis (Flesh eating bacteria)
Other important related pages relating to infections include:
Lymphadenopathy - Information on swollen lymph nodes
Blisters - Improper care of a simple boil can lead to severe consequences.
These pages give helpful information relating to treatment, prevention, and doctr care:
Antibiotics - Everyone should also have an updated list of medicines, doses and doctors prescribing the medicine.
Probiotics - Helpful in replacing the "good" bacteria that antibiotics kill.
Infectious Disease Doctor - The type of doctor who is best trained to treat and understand infections. I recommend that we all have one.
Feb 14 ,2012