Download MBBS Surgery Presentations 35 Lymphangitis Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 35 Lymphangitis PPT-Powerpoint Presentations and lecture notes

Lymphangitis

Lymphadenitis

Dept Of Surgery

Introduction

? Lymphatic system encompasses a network of vessels, glands,

and organs located throughout the body.

? Transports fluids, fats, proteins, and other substances in the

body.

? Lymph nodes filter the lymph fluid.

? Foreign bodies such as bacteria and viruses are processed in

the lymph nodes to generate an immune response to fight

infection.


When pathogenic organisms enter the lymphatic

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.

Bacteria can grow rapidly in the lymphatic system
Definition

Inflammation of the lymphatic channels that

occurs as a result of infection at a site distal to

the channel

Etiology

? Species of group A beta-hemolytic streptococci (GABHS) (MC)
? Staphylococcus aureus
? Pseudomonas species
? Streptococcus pneumoniae
? Pasteurel a multocida
? Gram-negative rods, gram-negative bacil i, and fungi
? Aeromonas hydrophila
? Wuchereria bancrofti

Diabetes, immunodeficiency, varicel a, chronic steroid use, or other

systemic il nesses have increased risk of developing serious or rapidly

spreading lymphangitis.
Nodular lymphangitis
Superficial inoculation with one of the fol owing organisms:

? Sporothrix schenckii
? Nocardia brasiliensis
? Mycobacterium marinum
? Leishmania panamensis
? L guyanensis
? Francisella tularensis

Prognosis

? With uncomplicated lymphangitis is good.

? Antimicrobial regimens are effective in more than 90% of

cases.

? Without appropriate antimicrobial therapy cellulitis may

extend along the channels; necrosis and ulceration may occur.

? Morbidity and mortality is related to the underlying infection.

? Mortality associated with lymphangitis alone, lymphangitis

caused by GABHS can lead to bacteremia, sepsis, and death.




Clinical presentation

? H/o minor trauma to an area of skin distal to the site of

infection

? Children with lymphangitis: fever, chil s, and malaise,

headache, loss of appetite, muscle aches.

? H/o recent cut or abrasion or of an area of skin

? Can progress rapidly to bacteremia and disseminated

infection and sepsis
Physical examination

? Erythematous and irregular linear streaks extend from the primary

infection site toward draining regional nodes.

? Primary site may be an abscess, an infected wound or an area of

cel ulitis

? Blistering of the affected skin may occur

? Lymph nodes associated with the infected lymphatic channels are

often swollen and tender

? Patients may be febrile and tachycardic

Differential diagnosis

? Contact dermatitis
? Cel ulitis
? Septic thrombophlebitis
? Superficial thrombophlebitis
? Necrotizing fasci tis
? Myositis
? Sporotrichosis
Investigations

? Complete blood cell (CBC) count
? Blood culture
? Leading -edge culture or aspiration of pus
? Cultures and Gram staining of fluid.

Threshold sensitivity of Gram staining: 100,000 microorganisms per

mil iliter, concentration rarely found in cel ulitis or lymphangitis.

A study found that multidetector computed tomography (MDCT)
imaging was very useful in determining the morphology (cellulitis
with a few small subcutaneous nodules and channels) and the
extension of the lesion in a case of nodular lymphangitis caused
by Mycobacterium marinum
Management

? Antibiotics

? Oral
? Parenteral (with signs of systemic illness (eg, fever,

chills and myalgia, lymphangitis).

? Analgesics
? Anti -inflammatory
? Elevation and immobilization of affected areas reduces

swel ing, pain, and the spread of infection. An abscess

may require surgical drainage.

Nodular lymphangitis

? Treatment of nodular lymphangitis is determined by

identifying the underlying cause.

? Sporotrichosis is most often identified in this disease

and is commonly found among gardeners.


Antibiotics

? Dicloxacillin
? Cephalexin
? Cefazolin
? Cefuroxime
? Ceftriaxone
? Clindamycin
? Nafcillin
? Trimethoprim and sulfamethoxazole (TMP/SMZ)

Lymphadenitis
Lymphadenitis

acute or chronic

Rarely biopsied

Classification


predominant histologic

pattern

etiology

Lymphadenitis - etiology

Microbial
? viral
? bacterial, mycobacterial
? fungal
? Protozoal
Nonmicrobial -

Autoimmune
storage disease
Lymph node inflammation

Lymph node hyperplasia:

1. follicular

2. paracortical

3. sinuses

4. mixed patterns

Lymph node inflammation - patterns

? Follicular hyperplasia

bacteria, RA, HIV(early), syphilis,
Castleman dis.

? Paracortical hyperplasia

viruses, dermatopathies, vaccination,
drug hypersensitivity, Kikuchi, SLE,
draining pus or carcinoma


Suppurative Bacterial Lymphadenitis

? Staphylococcus aureus and Group A Streptococcus
? Anaerobes
? Usually acute onset, fever, CBC
? Management: antibiotics
? If not resolving or getting worse

? Ultrasound and/or CT with contrast to evaluate for

phlegmon/abscess/infiltrate

? FNA vs Surgical I&D vs Surgical Excision if abscess is identified

Suppurative Lymphadenitis with Overlying

cel ulitis
Subacute Lymphadenitis

? 2-6 weeks
? Usually no improvement with antibiotics
? DD:

? Atypical Mycobacteria
? Cat Scratch disease
? Toxoplasmosis
? TB

Atypical Mycobacteria

? Leading cause of sub-acute disease
? Species involved:

?

Mycobacterium avium-intrucellulare

?

Mycobacterium scrofulaceum

? Develops over weeks to months
? Lymph nodes may have violaceous skin over the node
? No fever, normal behavior, no pain
? Diagnosis: acid fast stain and culture, can take weeks. PCR.
? Treatment: surgical excision of involved lymph nodes, some offer

antibiotics (Clarithromycin plus Rifabutin)


Tuberculosis lymphadenitis

(Scrofula)

Presenting Signs and Symptoms

Cervical nodes most commonly involved

Stages of Tubercular Lymphadenitis -
? Lymphadenitis
? Periadenitis
? Cold abscess
? 'Collar stud' abscess
? Sinus

Tuberculosis (Scrofula)
Tuberculous lymphadenitis is popularly known as Collar
stud abscess, due to its proximity to the collar bone and
superficial resemblance to a collar stud

History

? Fever, malaise, anorexia, myalgias
? Pain or tenderness of node
? Sore Throat / URI / Toothache / Ear pain
? Insect Bites
? Exposure to animals
? History of travel or exposure to TB
? Immunizations
? Medications
Physical Exam

? General

? Febrile or toxic appearing

? Skin

? Cellulitis, impetigo, rash

? ENT

? Otitis, pharyngitis, teeth, and nasal cavity

? Neck

? Size

? Unilateral vs Bilateral

? Tender vs Nontender

? Mobile vs Fixed

? Hard vs Soft

? Lungs

? Consolidations suggesting TB

? Abdomen

? Hepatosplenomegaly

Laboratory Workup

? CBC with Differential
? ESR
? Throat culture
? Serology

? EBV, CMV, Toxoplasmosis, Bartonella, Syphilis, HIV

? LDH, uric acid


Imaging Workup

? CXR if malignancy sus.

? To look for mediastinal lymphadenopathy

? Ultrasound

? Abscess?

? Benign vs. malignant

? Sometimes CT/MRI

? To evaluate for abscess

? EKG/ECHO

? If suspect Kawasaki Disease

? Biopsy

? FNA or Excisional
Treatment

Incision drainage with proper evacuation of the

abscess, followed by anti-tubercular antibiotic

treatment.