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Lymphangitis

Lymphangitis
Literature review current through: Jan 2024.
This topic last updated: Jan 29, 2024.

INTRODUCTION — Lymphangitis is inflammation of lymphatic channels due to infectious or noninfectious causes. Potential pathogens include bacteria, mycobacteria, viruses, fungi, and parasites. Lymphangitis most commonly develops after cutaneous inoculation of microorganisms into the lymphatic vessels through a skin wound or as a complication of a distal infection.

This topic reviews the various forms of lymphangitis, ranging from acute, rapidly progressive disease to subacute or chronic granulomatous inflammation. Numerous infectious and noninfectious causes are discussed for each of the clinical presentations.

PATHOPHYSIOLOGY — A major function of the lymphatic system is to resorb fluid and protein from tissues and extravascular spaces. The absence of a basement membrane beneath lymphatic endothelial cells affords the lymphatic channels a unique permeability, allowing resorption of proteins that are too large to be resorbed by venules.

Lymphatic channels are situated in the deep dermis and subdermal tissues parallel to the veins and have a series of valves to ensure one-way flow [1]. Lymph drains via afferent lymphatics to regional lymph nodes and then by efferent lymphatics to the cisterna chyli and the thoracic duct into the subclavian vein and venous circulation.

Lymphangitis due to infection most commonly develops after cutaneous inoculation of microorganisms that invade the lymphatic vessels and spread toward the regional lymph nodes; organisms may invade lymphatic vessels directly through a skin wound or abrasion or as a complication of distal infection. Lymphangitis can also be caused by inflammation of lymphatic vessels without an infectious cause [2].

ACUTE LYMPHANGITIS — Acute lymphangitis is characterized by tender, erythematous streaks extending proximally up an extremity, sometimes with involvement of regional lymph nodes (lymphadenitis). Proximal progression of the lymphangitic streaks occurs rapidly, in some cases over a few hours. Infection is the most common cause, although noninfectious cases can occur.

Infectious causes — Acute lymphangitis most often occurs in patients with cellulitis or erysipelas of an extremity. Patients often have systemic symptoms of infection, including fever.

The most common pathogens are those that cause cellulitis and erysipelas, primarily Streptococcus pyogenes (Group A Streptococcus) and, less commonly, Staphylococcus aureus. In immunocompromised patients, gram-negative organisms are also important causes of lymphangitis. (See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis", section on 'Microbiology' and "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)

More unusual causes of localized skin infection and acute lymphangitis include Pasteurella multocida (from cat and dog bites) and Spirillum minus (from rodent bites). Additionally, certain tick-borne spotted fever group rickettsial infections (eg, Rickettsia africae, Rickettsia sibirica) have been associated with lymphangitis and systemic illness; the presence of an eschar and specific geographic exposure may suggest these infections [3-5]. (See "Pasteurella infections" and "Rat bite fever" and "Other spotted fever group rickettsial infections", section on 'R. africae (African tick bite fever)' and "Other spotted fever group rickettsial infections", section on 'R. sibirica infection'.)

Noninfectious causes — Uncommonly, noninfectious conditions may elicit an acute inflammatory lymphangitis. Arthropod bites, especially spider and scorpion bites, can elicit extensive inflammation [2,6-10]. Topical medications (eg, cantharidin), peripheral intravenous catheters, vaccinations, and tuberculin skin tests are also reported causes [11-14].

Typically, patients with noninfectious acute lymphangitis are able to recall the inciting event and do not have systemic symptoms or lymphadenopathy. (See "Diagnostic approach to the patient with a suspected spider bite: An overview" and "Scorpion envenomation causing skin necrosis, hemolysis, DIC, and acute kidney injury (Middle East)".)

NODULAR LYMPHANGITIS — Nodular lymphangitis is also known as sporotrichoid lymphangitis, sporotrichoid spread, or lymphocutaneous syndrome.

Clinical overview — Lymphangitis presents as painful or painless nodular subcutaneous swellings along the course of lymphatic channels [15-21]. Some lesions may ulcerate and have accompanying regional lymphadenopathy or lymphadenitis.

Most cases are due to infection by pathogens capable of causing granulomatous inflammation, necrosis, and cutaneous abscess. Many of the pathogens are ubiquitous in soil or water and are acquired by exposure of the skin to the organism in its environment.

The incubation period between the initial exposure and onset of nodular lymphangitis can be prolonged, and the presentation may be indolent (often over months). Systemic symptoms, such as fever, are typically absent.

A detailed clinical history, including occupational and recreational exposures, should be combined with careful clinical assessment.

Most patients have or recall an initial lesion that acted as the distal starting point for the lymphangitis. The nature of the primary lesion may aid the diagnosis. Painless ulcers may be observed in Sporothrix schenckii, leishmania (with or without satellite lesions), and Francisella tularensis infection, while tender lesions may be due to Nocardia or Mycobacterium marinum or other nontuberculous mycobacteria [16]. Initial lesions may manifest in a variety of forms.

In general, determining the etiology of nodular lymphangitis requires aspiration or biopsy of a nodule for histopathology, microbiologic stains, and culture. (See 'Approach to diagnosis' below.)

Fungal infections — Fungal infections are among the most common causes of nodular lymphangitis.

Sporotrichosis — Sporothrix spp is a dimorphic fungus that grows as a mold in the environment and as a yeast in human tissues. The organism exists in soil, plant debris, moss, hay, decaying wood, and other vegetation. Most patients report exposure to plants; gardening injury due to a thorn or wood splinter is commonly reported [15,22]. Transmission from animal bites and scratches has also been reported [20]. (See "Basic biology and epidemiology of sporotrichosis", section on 'Sources of infection'.)

Sporotrichosis can have an incubation period ranging from days to three months. Onset typically begins with a painless or mildly painful papule at the site of the initial injury that sometimes ulcerates, followed by similar lesions occurring along the proximal lymphatic tracts. The most common sites are the hand and forearm (picture 1 and picture 2) [16,17,22]. (See "Clinical features and diagnosis of sporotrichosis".)

Diagnosis is often presumptive based on the clinical history, although other causes of nodular lymphangitis have similar exposures to soil and plants. The diagnosis is confirmed by tissue culture, but growth can take several weeks. (See "Clinical features and diagnosis of sporotrichosis".)

Endemic mycoses — Endemic mycoses include blastomycosis, coccidioidomycosis, histoplasmosis, and paracoccidioidomycosis. Cases of nodular lymphangitis have been reported from each of these organisms [15,16,23-25].

However, most patients with skin infection from endemic mycoses do not have nodular lymphangitis. Usually, cutaneous infection presents as a single lesion or a cluster of lesions without a linear pattern (picture 3). In other cases, cutaneous disease is due to secondary skin involvement from disseminated infection.

Other fungal causes — Other fungi have been reported to cause nodular lymphangitis, including Cryptococcus spp, Scedosporium spp, Fusarium spp, Scopulariopsis spp, and dematiaceous fungi [22,26] . A case due to Aspergillus spp precipitated by a toenail clipping has been reported in an immunocompromised patient [27].

In Thailand, a 10-year case series of 53 patients with sporotrichoid lymphangitis revealed dematiaceous fungi (Exophila spp, Wangiella spp, Cladorrhinum spp) as the most common cause [28].

Bacterial infections — In addition to fungal infections, bacterial infections are commonly reported causes of nodular lymphangitis.

Mycobacteria

M. marinumM. marinum causes classic nodular lymphangitis. The organism is found in fresh and salt water and on fish and marine mammals. It has been described to cause "fish tank granuloma" because some patients report cleaning an aquarium or fish tank as the inciting event. Cases have also been reported in fish merchants, after swimming in unchlorinated pools, and after acquiring a splinter while working in a marsh [29-31]. (See "Soft tissue infections following water exposure".)

M. marinum has an incubation period of up to eight weeks [15,16]. Typical presentation begins with a papule at the site of injury that progresses to form nodules along proximal lymphatic vessels; lesions may ulcerate or form abscesses.  

Rapid-growing mycobacteriaM. chelonae, M. abscessus, and M. fortuitum have all been reported to cause nodular lymphangitis. These organisms live in water and moist soil, and cases have been reported following fishing, wading in rivers, and soaking feet for pedicures [32-36].

Most skin and soft tissue infections caused by these mycobacteria do not present as nodular lymphangitis; the most common presentation is clusters of subcutaneous nodules that may ulcerate and form abscesses.

Other mycobacteria – Cutaneous tuberculosis has many forms of disease; rarely, it has been reported to cause nodular lymphangitis, as have other species of mycobacteria [22].

Nocardia — Nocardia infections may present with cutaneous, subcutaneous, or lymphocutaneous manifestations following traumatic injury [18]. Nocardia brasiliensis is the most common species to cause nodular lymphangitis, although other Nocardia species can cause it as well [37-40]. (See "Nocardia infections: Epidemiology, clinical manifestations, and diagnosis".)

The organisms live in plant tissue, soil, and water, and exposures such as gardening, farming, insect bites, and skin trauma from thorns, splinters, or motor-vehicle accidents have been reported. Most patients report a tender nodule at the inoculation site that progresses up the proximal lymphatic vessels over a period of weeks. Unlike patients with other forms of nocardiosis, patients with cutaneous disease are often immunocompetent.

Tularemia — Francisella tularemia, the causative organism of tularemia, propagates in animals (especially rabbits and hares) in North America, Europe, Asia, and the Middle East. The infection can manifest in many forms; skin infection is usually acquired from arthropod bites (eg, ticks, mosquitoes, biting flies) or skin contact with animals (such as occurs with hunters, farmers, veterinarians, and others).

Most tularemia cases are of the "ulceroglandular" form, characterized by a primary papular or ulcerative lesion and regional lymphadenitis with or without lymphangitis. In some cases, linear lymphadenitis obscures the presence of lymphangitis [16,41,42]. (See "Tularemia: Microbiology, epidemiology, and pathogenesis", section on 'Epidemiology' and "Tularemia: Clinical manifestations, diagnosis, treatment, and prevention".)

Erysipelothrix — Erysipelothrix rhusiopathiae is a zoonotic bacterium that has been isolated from many animals, especially fish, crabs, marine mammals, pigs, and chickens. In humans, the infection has been reported in fish handlers, slaughterhouse workers, butchers, farmers, and taxidermists [43].

The infection begins two to seven days after exposure and manifests as painful, well-defined, violaceous lesions, typically on the hand. Slowly progressive lymphangitis and/or lymphadenitis reportedly occurs in 30 percent of infected patients; it is unclear what proportion of lymphangitis cases are characterized by nodular lesions as opposed to erythematous streaking lymphangitis [44]. (See "Erysipelothrix infection", section on 'Clinical manifestations'.)

Other bacterial causes — Numerous other bacterial causes of nodular lymphangitis have been reported:

MelioidosisBurkholderia pseudomallei causes melioidosis, an infection that affects multiple organ systems. Although the disease has been reported in many regions of the world, it is most common in China, southeast Asia, and Australia. The organism lives in wet soil and contaminated bodies of water.

Skin infection typically presents with skin ulcers, pustules, or crusted erythematous lesions. Nodular lymphangitis and lymphadenitis have been reported [22,45]. (See "Melioidosis: Epidemiology, clinical manifestations, and diagnosis".)

Cat-scratch diseaseBartonella henselae typically occurs after a cat scratch, lick, or bite. The primary inoculation lesion begins 3 to 10 days after exposure as a vesicle or papule. Around day 14 after exposure, proximal tender lymphadenopathy develops, the hallmark of the illness. Nodular lymphangitis has been reported [22,46]. (See "Microbiology, epidemiology, clinical manifestations, and diagnosis of cat scratch disease".)

Anthrax – The microorganism that causes of anthrax, Bacillus anthracis, primarily infects animals. The organism exists in soil as spores for many years, mainly in locations where animal carcasses once were. Cutaneous disease typically follows exposure of a cut or abrasion to infected soil or an infected animal or animal product.

Cutaneous anthrax begins as a painless, slowly enlarging papule that develops a central bulla followed by necrosis, leaving a black eschar. Extensive edema, regional lymphadenopathy, and lymphangitis are common; the frequency of nodular lymphangitis is unclear but has been reported (picture 4) [22,47]. (See "Clinical manifestations and diagnosis of anthrax", section on 'Clinical manifestations'.)

Group A Streptococcus (S. pyogenes) and Staphylococcus aureus – Although these bacteria are much more likely to cause acute skin infection and acute lymphangitis, a few cases of slowly progressive, nodular lymphangitis have been reported [15,48,49].

Parasitic infections — Leishmaniasis is the primary parasitic cause of nodular lymphangitis. Filariasis is known to cause a type of lymphangitis other than nodular disease, as discussed elsewhere. (See 'Filarial lymphangitis' below.)

Leishmaniasis — Leishmania is a protozoal parasite transmitted by the bite of a sandfly in Central and South America, the Middle East, Africa, Asia, and southcentral Texas.

Cutaneous leishmaniasis can present with subcutaneous nodules with lymphangitis or lymphadenitis up to 24 weeks following exposure [16,50]. This presentation is more frequent with New World leishmaniasis caused by Leishmania braziliensis or Leishmania mexicana than with Old World leishmaniasis due to Leishmania major or Leishmania tropica [15]. (See "Cutaneous leishmaniasis: Clinical manifestations and diagnosis".)

Viral infections — Although uncommon, numerous viral infections have been reported to cause nodular lymphangitis:

Herpes simplex virus (HSV) – HSV has been reported to cause lymphangitis, primarily in patients with herpetic whitlow of the finger or hand; the proportion of lymphangitis that is nodular is unclear [2,22,51,52]. The primary site of infection typically presents as a vesicle. (See "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection".)

Mpox – Monkeypox virus, the cause of mpox, is transmitted by direct contact with infectious sores, scabs, or body fluids. The primary rash begins as small macules and progresses to vesicles and pustules. Lymphangitis has been reported [53]. (See "Epidemiology, clinical manifestations, and diagnosis of mpox (monkeypox)".)

Other viruses – Parapoxvirus, a virus that causes a vesicular "milker's nodule" in patients who milk infected cows, has been reported to cause lymphangitis [14,54].

Noninfectious etiologies — A few causes of nodular lymphangitis due to conditions other than infections have been reported:

In-transit melanoma – As cutaneous melanoma spreads, it may follow the follow lymphatic vessels from primary lesion to the nearest proximal lymph node, creating a nodular lymphangitis. In most cases, in-transit melanoma occurs after excision of the primary lesion (picture 5) [55]. (See "Cutaneous melanoma: In-transit metastases".)

Sclerosing and granulomatous lymphangitis – Palpable nodular or ulcerative lymphangitis, usually of the scrotum and penis has been reported, particularly in patients with Crohn's disease [56-58].

Approach to diagnosis — In all cases of nodular lymphangitis, aspiration or biopsy of a nodule is typically necessary to determine the underlying etiology.

We request that samples be sent for the following:

Histopathologic evaluation as well as bacterial, mycobacterial, and fungal stains and cultures.

Based on our clinical suspicion, we advise the laboratory and pathologist to evaluate for suspected pathogens that may require special stains or culture techniques, such as nontuberculous mycobacteria, Sporothrix spp, endemic mycoses, Nocardia spp, F. tularensis, Erysipelothrix, B. henselae, B. pseudomallei, and B. anthracis.

If viral infection is suspected, we order viral cultures and notify the laboratories about the suspected viruses.

For leishmaniasis, we notify the histopathologist because visualization of the organisms may require extensive searching, and we obtain polymerase chain reaction (PCR).

Molecular techniques (eg, PCR) are being increasingly used for diagnosis of several of the pathogens known to cause nodular lymphangitis [59-64].

Radiographic imaging is typically not helpful for diagnosing most infectious forms of nodular lymphangitis. For patients with suspected malignancy, imaging is often of value.

OTHER FORMS OF LYMPHANGITIS

Filarial lymphangitis — Lymphangitis due to filariasis has distinctive clinical manifestations. The presence of the parasite within the lymphatic channels causes inflammation and subsequent dilatation, thickening, and tortuosity of the lymphatic channels with valvular incompetence. Filarial lymphangitis often occurs in a retrograde progression with distal or peripheral spread away from the regional lymph nodes where the adult parasite resides. Lymphangitis can also occur because of inflammation due to dying parasites. Subsequent lymphedema with thickening of skin and subcutaneous tissue can predispose to repeated episodes secondary bacterial infection (picture 6) [65,66].

Wuchereria bancrofti, Brugia malayi, and Brugia timori are the causes of lymphangitis due to lymphatic filariasis. Filarial lymphangitis is uncommon in short-term travelers but may be considered in individuals who have spent prolonged periods in endemic areas (figure 1). (See "Lymphatic filariasis: Epidemiology, clinical manifestations, and diagnosis".)

Lymphangitis at nonperipheral sites — In addition to involvement of distal extremities, lymphangitis can also present at nonperipheral sites. Examples include:

Mycobacterium tuberculosis can penetrate the ileocecal mucosa to reach the lymphoid tissue, which may generate an inflammatory response with lymphangitis. Patients may present with symptoms compatible with appendicitis.

Filariasis can present with genital lymphatic involvement of the testes, scrotum, and epididymis as well as involvement of the renal lymphatics resulting in discharge of intestinal lymph into the urine (chyluria). (See "Lymphatic filariasis: Epidemiology, clinical manifestations, and diagnosis".)

Lymphogranuloma venereum may spread from the primary site and cause a local lymphangitis of the scrotum or vulva [67,68]. (See "Lymphogranuloma venereum".)

Crohn's disease can cause granulomatous intestinal lymphangitis, which is believed to possibly contribute to the underlying pathophysiology of the disease [69].

Breast, lung, stomach, pancreas, rectal, and prostate cancers, as well as lymphoma, can cause internal localized lymphangitis of the lymphatics draining the primary site of the malignancy [70-73]. In patients with lung cancer, lymphatic spread of lung cancer within the lungs is termed lymphangitic carcinomatosa.

TREATMENT — Specific therapies for individual infections are discussed in detail separately. Some cases of nodular lymphangitis require surgical debridement. In the setting of lymphedema with significant lymphatic obstruction, surgical intervention may also be appropriate [74]. In some cases, pending diagnostic evaluation, empiric antibiotic therapy with activity against the most likely etiology may be initiated as outlined in detail separately. (See "Acute cellulitis and erysipelas in adults: Treatment".)

REFRACTORY AND RECURRENT LYMPHANGITIS — In patients with a confirmed etiology of lymphangitis, refractory or recurrent disease should prompt consideration for several possible causes:

Incorrect diagnosis – A careful re-evaluation of clinical information, including exposures, may prompt repeat aspiration or biopsy of affected tissue.

Resistant pathogen – For some infections, resistance can develop while on therapy. In some cases, repeat aspiration or biopsy for susceptibility testing can help guide further therapy.

Inadequate compliance – Patients may not take medications as scheduled for several reasons, including adverse effects and cost-related issues.

Comorbid conditions – Conditions such as peripheral vascular disease, extensive edema, and previously damaged lymphatic vessels (including lymphedema) may inhibit the ability of medication to reach the site of infection [75]. Immunocompromising conditions can also reduce the likelihood of cure.

Some patients are treated empirically for the most suspected etiology because initial studies were unavailable or unrevealing. In such cases, patients who are not responding should undergo thorough clinical evaluation and repeat biopsies to identify the etiology.

SUMMARY AND RECOMMENDATIONS

Pathophysiology – Lymphangitis is characterized by inflammation of the lymphatic vessels. It may be caused by infectious or noninfectious conditions. (See 'Pathophysiology' above.)

Acute lymphangitis – Acute lymphangitis is characterized by rapidly progressive, tender, erythematous streaks extending proximally up an extremity, sometimes with involvement of regional lymph nodes (lymphadenitis). Cellulitis and erysipelas are the most common causes, although noninfectious causes exist (eg, spider and scorpion bites, vaccinations). (See 'Acute lymphangitis' above.)

Nodular lymphangitis – Nodular lymphangitis presents as painful or painless nodular subcutaneous swellings along the course of lymphatic channels. Some lesions may ulcerate and have accompanying regional lymphadenopathy or lymphadenitis. Infections are the most common cause. (See 'Nodular lymphangitis' above.)

Fungal infections – Sporotrichosis is the classic cause of nodular lymphangitis. Other fungal etiologies include the endemic mycoses (eg, blastomycosis, coccidioidomycosis), dematiaceous fungi, and Scedosporium spp. (See 'Fungal infections' above.)

Bacterial infectionsMycobacterium marinum causes typical nodular lymphangitis, as can other forms of nontuberculous mycobacteria. Other bacterial causes include Nocardia spp, tularemia, Erysipelothrix, anthrax, and others. (See 'Bacterial infections' above.)

Parasitic infections – Leishmaniasis is the main parasitic cause of nodular lymphangitis, particularly the New World strains of Leishmania. (See 'Parasitic infections' above.)

Viral infections – Uncommonly, herpes simplex, monkeypox virus, and other viruses can cause nodular lymphangitis. (See 'Viral infections' above.)

Noninfectious etiologies – The most serious noninfectious cause of nodular lymphangitis is melanoma in-transit. (See 'Noninfectious etiologies' above.)

Other forms of lymphangitis – Other forms of lymphangitis include chronic lymphangitis due to filariasis and lymphangitis of the lymphatics in body organs and tissues other than the skin (eg, ileocecal lymphangitis due to tuberculosis or Crohn's disease). (See 'Other forms of lymphangitis' above.)

Treatment – Treatment of lymphangitis is targeted to the underlying cause of illness. (See 'Treatment' above.)

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