Rosen & Barkin's 5-Minute Emergency Medicine Consult (430 page)

DIAGNOSIS

• Acute lymphangitis:
  
  • Warm, tender erythematous streaks develop and extend proximally from the source of infection
    
  • Regional lymph nodes often become enlarged and tender (lymphadenitis).
    
  • Peripheral edema of involved extremity
    
  • Systemic manifestations:
    
    • Fever
      
    • Rigors
      
    • Tachycardia
      
    • Headache
      
• Chronic (nodular) lymphangitis:
  
  • Erythematous nodule, chancriform ulcer, or wart-like lesion develops in SC tissue at inoculation site
    
  • Often presents without pain or evidence of systemic infection
    
  • Multiple lesions possible along lymphatic chain
    

History and physical exam directed at discovering source of infection

• Fever
  
• Erythematous streaks from source of infection proceeding toward regional lymph nodes
  

Lymphangitis is a clinical diagnosis

• WBC is unnecessary but often elevated
  
• Gram stain and culture of initial lesion to focus antimicrobial selection and reveal resistant pathogens (MRSA):
  
  • Aspirate point of maximal inflammation or punch biopsy
    
  • Essential if treatment failure
    
• If sporotrichosis or
  M. marinum
  infection is suspected, diagnosis should be confirmed by culture of organism from wound
  
• Blood culture may reveal organism
  

• Imaging is not commonly performed
  
• Plain radiographs may reveal abscess formation, SC gas, or foreign bodies if these are suspected
  
• Extremity vascular imaging (doppler US) can help rule out deep venous thrombosis
  

• Thrombophlebitis; deep venous and superficial:
  
  • Differentiation from lymphangitis:
    
    • Absence of initial traumatic or infectious focus
      
    • No regional lymphadenopathy
      
• IV line infiltration
  
• Smallpox vaccination, normal variant of usual reaction to vaccination
  
• Phytophotodermatitis:
  
  • Linear inflammatory reaction, mimics lymphangitis
    
  • Lime rind, lime juice, and certain plants can act as photosensitizing agents
    

TREATMENT

If patient is septic, manage airway and resuscitate as indicated

• Antimicrobial therapy should be initiated with first dose in ED
  
• General principles:
  
  • Consider local prevalence of MRSA and other resistant pathogens in addition to usual causes
    
  • Usual outpatient treatment: 7–10 days
    
  • Elevation
    
  • Application of moist heat
    
• Acute lymphangitis, empiric coverage:
  
  • Outpatient:
    
    • Oral cephalexin plus trimethoprim/sulfamethoxazole (TMP/SMX) (to cover CA-MRSA)
      
    • Alternatives to cephalexin: Oral dicloxacillin, macrolide, or levofloxacin
      
    • Alternatives to TMP/SMX: Clindamycin or doxycycline
      
• Inpatient: IV nafcillin or equivalent
  
• Lymphangitis after dog or cat bite: IV ampicillin/sulbactam
  
• MRSA:
  
  • Nosocomial MRSA: IV vancomycin or PO or IV linezolid
    
  • CA-MRSA:
    
    • PO: TMP/SMX, clindamycin, or doxycycline
      
    • IV: Vancomycin or clindamycin
      
• Sporotrichosis:
  
  • Itraconazole or saturated solution of potassium iodide (SSKI)
    
• M. marinum
  :
  
  • Localized granulomas are usually excised
    
  • Antimicrobial therapy is usually reserved for more severe infections:
    
    • Limited data on what combination of agents should be used
      
    • Rifampin and ethambutol may be best choice
      

• Ampicillin/sulbactam: 1.5–3 g (peds: 100–300 mg/kg/24 h up to 40 kg; >40 kg, give adult dose) IV q6h
  
• Cephalexin: 500 mg (peds: 50–100 mg/kg/24 h) PO QID
  
• Clindamycin: 450–900 mg (peds: 20–40 mg/kg/24h) PO or IV q6h
  
• Dicloxacillin: 125–500 mg (peds: 12.5–25 mg/kg/24h) PO q6h
  
• Doxycycline: 100 mg PO BID for adults
  
• Erythromycin base: (Adult) 250–500 mg PO QID
  
• Itraconazole (adult): 200 mg PO daily, continue until 2–4 wk after all lesions resolve (usually 3–6 mo); peds: Not approved for use
  
• Levofloxacin: (Adult only) 500–750 mg PO or IV daily
  
• Linezolid: 600 mg PO or IV q12h (peds: 30 mg/kg/24 h div. q8h)
  
• Nafcillin: 1–2 g IV q4h (peds: 50–100 mg/kg/24 h div. q6h); max. 12 g/24 h
  
• Rifampin: 600 mg PO BID for adults
  
• TMP/SMX: 2 DS tabs PO q12h (peds: 6–10 mg/kg/24 h TMP div. q12h)
  
• Vancomycin: 1 g IV q12h (peds: 10 mg/kg IV q6h, dosing adjustments required for age <5 yr); check serum levels
  

FOLLOW-UP

• Toxic appearing
  
• History of immune suppression
  
• Concurrent chronic medical illnesses
  
• Unable to take oral medications
  
• Unreliable patients
  

• Mild infection in a nontoxic-appearing patient
  
• Able to take oral antibiotics
  
• No history of immune suppression or concurrent medical problems
  
• Adequate follow-up within 24–48 hr
  

• Follow-up within 24–48 hr
  
• Sooner if worsening symptoms, including worsening fever or other systemic symptoms
  
• Outline the border of erythema before discharge to aid in assessing response to therapy
  

Empiric antibiotic coverage must extend to include CA-MRSA, in addition to coverage for other staph species and strep.

• Pasternack MS, Swartz MN. Lymphadenitis and lymphangitis. In: Mandell GL, Bennett JE, Dolin R, eds.
  Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases
  . 7th ed. New York, NY: Elsevier/Churchill Livingstone; 2010:1323–1334.
  
• Rex JH, Okhuysen PC. Sporothrix schenckii. In: Mandell GL, Bennett JE, Dolin R, eds.
  Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases
  . 7th ed. New York, NY: Elsevier/Churchill Livingstone; 2010:3271–3276.
  
• Smego RA, Castiglia M, Asperilla MO. Lymphocutaneous syndrome: A review of nonsporothrix causes.
  Medicine (Baltimore)
  . 1999;78:38–63.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Cellulitis
  
• Lymphadenitis
  
• MRSA
  

CODES

• 041.12 Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site
  
• 457.2 Lymphangitis
  
• 682.9 Cellulitis and abscess of unspecified sites
  

BASICS