AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

The lymphatic system encompasses a network of vessels, glands, and organs located throughout the body. Functioning as part of the immune system, it also transports fluids, fats, proteins, and other substances in the body. Lymph nodes or glands filter the lymph fluid. Foreign bodies, such as bacteria or viruses, are processed in the lymph nodes to generate an immune response to fight an infection. Lymphangitis is defined as an inflammation of the lymphatic channels that occurs as a result of infection at a site distal to the channel. Pathogenic organisms invade the lymphatic vessels and spread along these channels toward regional lymph nodes. The infected lymphatic vessel becomes inflamed. Bacteria can rapidly grow in the lymphatic system.

Pathophysiology

Pathogenic organisms enter the lymphatic channels directly through an abrasion or wound or as a complication of infection. After the organisms enter the channels, local inflammation and subsequent infection ensue, manifesting as red streaks on the skin. The inflammation or infection then extends proximally toward regional lymph nodes.

Frequency

United States

No specific data are available.

International

No specific data are available.

Mortality/Morbidity

Although no specific data are available as to the mortality and morbidity associated with lymphangitis alone, those patients with lymphangitis due to group A streptococcal infections are at increased risk for significant morbidity and mortality. The morbidity and mortality associated with lymphangitis is related to the underlying infection.

Race

No specific data are available.

Sex

Although no specific data are available for lymphangitis, two thirds of children with cellulitis (a complication occurring in the absence of appropriate antimicrobial therapy) are reported to be male.

Age

No age predilection is reported.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

A history of minor trauma to an area of skin distal to the site of infection is often elicited.

• Children with lymphangitis often have fever, chills, and malaise.
• Some children may report a headache, loss of appetite, and muscle aches.
• Patients often have a history of a recent cut or abrasion or of an area of skin that appears infected and spreading.
• Lymphangitis can progress rapidly to bacteremia and disseminated infection and sepsis, particularly when caused by group A streptococci.

Physical

• Upon clinical examination, erythematous and irregular linear streaks extend from the primary infection site toward draining regional nodes.
• • These streaks may be tender and warm.
  • The primary site may be an abscess, an infected wound, or an area of cellulitis.
  • Blistering of the affected skin may occur.


• Lymph nodes associated with the infected lymphatic channels are often swollen and tender.
• Children may be febrile and tachycardic.

Causes

• In individuals with normal host defenses, group A beta-hemolytic streptococcal (GABHS) species are the most common causes of lymphangitis.
• • GABHS elaborate fibrinolysins and hyaluronidase, which aid their invasion of lymphatic channels.
  • Lymphangitis caused by GABHS can rapidly progress and has been associated with serious complications.
  • Lymphangitis is more likely to occur in patients with cellulitis due to GABHS than in patients with cellulitis caused by Staphylococcus aureus.
• Other organisms include S aureus and Pseudomonas species.
• Streptococcus pneumoniae is a relatively uncommon cause of lymphangitis.
• Pasteurella multocida, associated with dog and cat bites, can cause cellulitis and lymphangitis.
• In immunocompromised hosts, gram-negative rods, gram-negative bacilli, and fungi may cause cellulitis and resultant lymphangitis.
• Wounds that occur in fresh water can become contaminated with Aeromonas hydrophila.
• Worldwide, Wuchereria bancrofti is a major cause of acute lymphangitis. Signs and symptoms of lymphangitis caused by W bancrofti are indistinguishable from those of lymphangitis caused by bacteria.
• Children with diabetes, immunodeficiency, varicella, chronic steroid use, or other systemic illnesses have increased risk of developing serious or rapidly spreading lymphangitis.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Cellulitis
Septic thrombophlebitis
Superficial thrombophlebitis
Necrotizing fasciitis
Myositis
Sporotrichosis

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• In any child who presents with lymphangitis, a CBC count and blood culture should be obtained. In addition, a leading-edge culture or aspiration of pus should be considered.
• The CBC count and differential often reveal marked leukocytosis.
• Blood cultures may reveal that infection has spread to the bloodstream; however, results are rarely positive.
• Culture and Gram staining of aspirate from the primary site of infection may help in identifying the infectious organism and in choosing antimicrobials.
• • Some authors recommend aspiration of the leading edge of the infection; others prefer sampling the area of maximum inflammation.
  • Data from a small comparative study appear to suggest that aspiration of the area of maximal inflammation may increase the yield positive cultures. However, aspiration is relatively insensitive for diagnosing causative organisms. The low density of pathogens present in the infected tissue results in the low sensitivity of aspiration.
  • The threshold sensitivity of Gram staining is approximately 100,000 microorganisms per milliliter, a concentration rarely found in cellulitis or lymphangitis.
  • Aspiration of the leading edge of maximal inflammation is not thought to be helpful in the acute management of cases of acute lymphangitis.

Imaging Studies

• Plain radiographs are unnecessary in routine cases.

Procedures

• Abscessed areas may require incision and drainage.
• Cultures and Gram staining of fluid may help identify the causative organism and help select appropriate antimicrobial agents.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• Treat children with lymphangitis with an appropriate antimicrobial agent.
• Children in stable social situations who appear nontoxemic and who are older than 3 years, afebrile, and well hydrated may be treated initially with oral (PO) antibiotics on an outpatient basis. Ensure close follow up.
• Parenteral antibiotics may be required for a patient with signs of systemic illness (eg, fever, chills and myalgia, lymphangitis).
• Aggressively treat suspected cases of GABHS; these cases can progress rapidly and have been associated with serious complications.
• Analgesics can be used to control pain, and anti-inflammatory medications can help reduce inflammation and swelling. Hot, moist compresses also help reduce inflammation and pain.

Consultations

An abscess may require surgical drainage.

Activity

If possible, elevate and immobilize affected areas to reduce swelling, pain, and the spread of infection.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Treat children with lymphangitis with an appropriate antimicrobial agent. Analgesics can help control pain, and anti-inflammatory medications can help reduce inflammation and swelling.

Drug Category: Antibiotics

Provide empiric coverage for group A streptococcal species and S aureus. Acceptable outpatient regimens include penicillinase-resistant synthetic penicillin or a first-generation cephalosporin. Acceptable inpatient regimens include a second- or third-generation cephalosporin (eg, cefuroxime, ceftriaxone) or a penicillinase-resistant synthetic penicillin. In certain geographical areas of the country with high rates of methicillin-resistant S aureus (MRSA), alternative antimicrobial agents such as clindamycin or trimethoprim-sulfamethoxazole (TMP-SMZ) should be considered.

Drug Name	Cephalexin (Keflex, Biocef, Keftab)
Description	First-generation cephalosporin. Arrests bacterial growth by inhibiting bacterial cell-wall synthesis; provides bactericidal activity against rapidly growing organisms.
Adult Dose	500 mg PO q6h
Pediatric Dose	50 mg/kg/d PO divided q6h
Contraindications	Documented hypersensitivity
Interactions	Coadministration with aminoglycosides increases nephrotoxic potential
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in renal impairment

Drug Name	Nafcillin (Nafcil, Unipen, Nallpen)
Description	Binds to 1 or more penicillin-binding proteins, which in turn inhibits synthesis of bacterial cell walls. Because of thrombophlebitis, administer parenterally for only 1-2 d; change to PO as clinically indicated.
Adult Dose	2 g IV q4h
Pediatric Dose	150 mg/kg/d IV divided q6h
Contraindications	Documented hypersensitivity
Interactions	Warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Thrombophlebitis

Drug Name	Cefazolin (Ancef, Kefzol, Zolicef)
Description	First generation semi-synthetic cephalosporin that arrests bacterial cell-wall synthesis, inhibiting bacterial growth.
Adult Dose	1 g IV q8h
Pediatric Dose	20 mg/kg/dose IV q8h
Contraindications	Documented hypersensitivity
Interactions	Probenecid prolongs effect; coadministration with aminoglycosides may increase renal toxicity; may yield false-positive result urine dip test for glucose
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in renal impairment

Drug Name	Cefuroxime (Kefurox, Zinacef)
Description	Second-generation cephalosporin that arrests bacterial cell-wall synthesis, inhibiting bacterial growth.
Adult Dose	2.25-6 g/d IV q6-8h
Pediatric Dose	50-100 mg/kg/d IV divided q6-8h
Contraindications	Documented hypersensitivity
Interactions	Disulfiram-like reactions may occur when alcohol consumed within 72 h after dose; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patient receiving potent diuretics (eg, loop diuretics); coadministration with aminoglycosides increase nephrotoxic potential
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in renal impairment

Drug Name	Ceftriaxone (Rocephin)
Description	Third-generation cephalosporin arrests bacterial growth by binding to 1 or more penicillin-binding proteins.
Adult Dose	1-2 g/d IV divided q12-24h
Pediatric Dose	50-75 mg/kg/d IV divided q12-24h
Contraindications	Documented hypersensitivity
Interactions	Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, or aminoglycosides may increase nephrotoxicity
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Adjust dose in renal impairment; caution in breastfeeding women and in persons with allergy to penicillin

Drug Name	Clindamycin (Cleocin)
Description	Semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl transfer RNA (tRNA) from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys. Used to treat serious skin and soft-tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci).
Adult Dose	150-300 mg/dose PO q6-8h; not to exceed 1.8 g/d; alternatively, 600 mg IV divided q8h, depending on degree of infection; not to exceed 4.8 g/d
Pediatric Dose	8-20 mg/kg/d PO as hydrochloride and 8-25 mg/kg/d as palmitate divided tid/qid; not to exceed 1.8 g/d 20-40 mg/kg/d IV/IM divided tid/qid; not to exceed 4.8 g/d
Contraindications	Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis
Interactions	Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile

Drug Name	TMP-SMZ (Bactrim, Septra)
Description	Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity includes common urinary-tract pathogens except Pseudomonas aeruginosa.
Adult Dose	160 mg TMP/800 mg SMZ PO q12h for 10-14 d
Pediatric Dose	<2 months: Do not administer >2 months: 10-20 mg TMP/kg/d PO/IV divided tid/qid for 14 d
Contraindications	Documented hypersensitivity; megaloblastic anemia due to folate deficiency; age <2 months
Interactions	May increase PT with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone-marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Do not use during last trimester of pregnancy due to potential toxicity to newborn (eg, jaundice, hemolytic anemia, kernicterus) Dosage adjustments (adult adjustments) for creatinine clearance (CrCl) 80-50 mL/min, recommended IV dosage is q18h; CrCl 50-10 mL/min, recommended IV dosage is q24h; CrCl <10 mL/min, not recommended; hemodialysis (HD), 4-5 mg/kg after HD; during peritoneal dialysis (PD), 0.16-0.8 g q48h Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue if clinically significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone-marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (chronic alcoholism, elderly, patients receiving anticonvulsant therapy or with malabsorption syndrome); hemolysis may occur in people with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Some patients may require admission for intravenous (IV) antimicrobial therapy.
• Most authors recommend that children younger than 3 years or children who are febrile and who appear toxic initially be treated with IV antibiotics.
• Children who have not improved clinically after 48 hours of appropriate PO antimicrobial therapy should receive IV antistaphylococcal and antistreptococcal therapy.
• When erythema, warmth, and edema are markedly reduced, antibiotics can be changed to the PO route.

Complications

• Lymphangitis may spread within hours.
• Bacteremia and sepsis can occur.
• Without appropriate antimicrobial therapy, cellulitis may develop or extend along the channels; necrosis and ulceration may occur.
• Lymphangitis caused by GABHS can progress rapidly, leading to bacteremia, sepsis, and death.

Prognosis

• The prognosis for patients with uncomplicated lymphangitis is good.
• Antimicrobial regimens are effective in more than 90% of cases.

Patient Education

• For excellent patient education resources, visit eMedicine's Blood and Lymphatic System Center. Also, see eMedicine's patient education article Swollen Lymph Glands.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to provide timely and appropriate antimicrobial therapy may lead to cellulitis, abscess formation, bacteremia, and sepsis.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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• Brook I. Management of human and animal bite wounds: an overview. Adv Skin Wound Care. May 2005;18(4):197-203. [Medline].
• Brook I. Microbiology and management of human and animal bite wound infections. Prim Care. Mar 2003;30(1):25-39, v. [Medline].
• Brown G, Chamberlain R, Goulding J, Clarke A. Ceftriaxone versus cefazolin with probenecid for severe skin and soft tissue infections. J Emerg Med. Sep-Oct 1996;14(5):547-51. [Medline].
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• Howe PM, Eduardo Fajardo J, Orcutt MA. Etiologic diagnosis of cellulitis: comparison of aspirates obtained from the leading edge and the point of maximal inflammation. Pediatr Infect Dis J. Jul 1987;6(7):685-6. [Medline].
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• Kazura JW, Spark R, Forsyth K, et al. Parasitologic and clinical features of bancroftian filariasis in a community in East Sepik Province, Papua New Guinea. Am J Trop Med Hyg. Nov 1984;33(6):1119-23. [Medline].
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• Sadick NS. Current aspects of bacterial infections of the skin. Dermatol Clin. Apr 1997;15(2):341-9. [Medline].
• Santos JI, Jacobson JA, Swensen P, Palmer WM. Cellulitis: treatment with cefoxitin compared with multiple antibiotic therapy. Pediatrics. Jun 1981;67(6):887-90. [Medline].
• Schwartz R, Das-Young LR, Ramirez-Ronda C, Frank E. Current and future management of serious skin and skin-structure infections. Am J Med. Jun 24 1996;100(6A):90S-95S. [Medline].
• Sigurdsson AF, Gudmundsson S. The etiology of bacterial cellulitis as determined by fine-needle aspiration. Scand J Infect Dis. 1989;21(5):537-42. [Medline].
• Yagupsky P. Bacteriologic aspects of skin and soft tissue infections. Pediatr Ann. Apr 1993;22(4):217-24. [Medline].

Article Last Updated: Jun 29, 2007