Download MBBS Surgery Presentations 35 Lymphangitis Lecture Notes

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Dept Of Surgery

Introduction

? Lymphatic system encompasses a network of vessels, glands,

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and organs located throughout the body.

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

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body.

? Lymph nodes filter the lymph fluid.

? Foreign bodies such as bacteria and viruses are processed in

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the lymph nodes to generate an immune response to fight

infection.

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When pathogenic organisms enter the lymphatic

channels local inflammation and subsequent infection

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ensue, manifesting as red streaks on the skin.

The inflammation or infection then extends proximally

toward regional lymph nodes.

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Bacteria can grow rapidly in the lymphatic system
Definition

Inflammation of the lymphatic channels that

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occurs as a result of infection at a site distal to

the channel

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Etiology

? Species of group A beta-hemolytic streptococci (GABHS) (MC)
? Staphylococcus aureus
? Pseudomonas species

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? Streptococcus pneumoniae
? Pasteurel a multocida
? Gram-negative rods, gram-negative bacil i, and fungi
? Aeromonas hydrophila
? Wuchereria bancrofti

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

systemic il nesses have increased risk of developing serious or rapidly

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

? Sporothrix schenckii

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

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Prognosis

? With uncomplicated lymphangitis is good.

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? Antimicrobial regimens are effective in more than 90% of

cases.

? Without appropriate antimicrobial therapy cellulitis may

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extend along the channels; necrosis and ulceration may occur.

? Morbidity and mortality is related to the underlying infection.

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? Mortality associated with lymphangitis alone, lymphangitis

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

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Clinical presentation

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

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infection

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

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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

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infection and sepsis
Physical examination

? Erythematous and irregular linear streaks extend from the primary

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infection site toward draining regional nodes.

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

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cel ulitis

? Blistering of the affected skin may occur

? Lymph nodes associated with the infected lymphatic channels are

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often swollen and tender

? Patients may be febrile and tachycardic

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Differential diagnosis

? Contact dermatitis
? Cel ulitis
? Septic thrombophlebitis

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? Superficial thrombophlebitis
? Necrotizing fasci tis
? Myositis
? Sporotrichosis
Investigations

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

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Threshold sensitivity of Gram staining: 100,000 microorganisms per

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

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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

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Management

? Antibiotics

? Oral

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

chills and myalgia, lymphangitis).

? Analgesics

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

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

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may require surgical drainage.

Nodular lymphangitis

? Treatment of nodular lymphangitis is determined by

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identifying the underlying cause.

? Sporotrichosis is most often identified in this disease

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and is commonly found among gardeners.


Antibiotics

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? Dicloxacillin
? Cephalexin
? Cefazolin
? Cefuroxime
? Ceftriaxone

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? Clindamycin
? Nafcillin
? Trimethoprim and sulfamethoxazole (TMP/SMZ)

Lymphadenitis

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Lymphadenitis

acute or chronic

Rarely biopsied

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Classification


predominant histologic

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pattern

etiology

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Lymphadenitis - etiology

Microbial
? viral
? bacterial, mycobacterial

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? fungal
? Protozoal
Nonmicrobial -

Autoimmune

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storage disease
Lymph node inflammation

Lymph node hyperplasia:

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1. follicular

2. paracortical

3. sinuses

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4. mixed patterns

Lymph node inflammation - patterns

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? Follicular hyperplasia

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

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? Paracortical hyperplasia

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

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Suppurative Bacterial Lymphadenitis

? Staphylococcus aureus and Group A Streptococcus

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? Anaerobes
? Usually acute onset, fever, CBC
? Management: antibiotics
? If not resolving or getting worse

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? Ultrasound and/or CT with contrast to evaluate for

phlegmon/abscess/infiltrate

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

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Suppurative Lymphadenitis with Overlying

cel ulitis
Subacute Lymphadenitis

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

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? Atypical Mycobacteria
? Cat Scratch disease
? Toxoplasmosis
? TB

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Atypical Mycobacteria

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

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?

Mycobacterium avium-intrucellulare

?

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Mycobacterium scrofulaceum

? Develops over weeks to months
? Lymph nodes may have violaceous skin over the node

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? 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)

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Tuberculosis lymphadenitis

(Scrofula)

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Presenting Signs and Symptoms

Cervical nodes most commonly involved

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

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? Sinus

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

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superficial resemblance to a collar stud

History

? Fever, malaise, anorexia, myalgias

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? Pain or tenderness of node
? Sore Throat / URI / Toothache / Ear pain
? Insect Bites
? Exposure to animals
? History of travel or exposure to TB

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? Immunizations
? Medications
Physical Exam

? General

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? Febrile or toxic appearing

? Skin

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? Cellulitis, impetigo, rash

? ENT

? Otitis, pharyngitis, teeth, and nasal cavity

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? Neck

? Size

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? Unilateral vs Bilateral

? Tender vs Nontender

? Mobile vs Fixed

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? Hard vs Soft

? Lungs

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? Consolidations suggesting TB

? Abdomen

? Hepatosplenomegaly

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Laboratory Workup

? CBC with Differential
? ESR

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? Throat culture
? Serology

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

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? LDH, uric acid


Imaging Workup

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? CXR if malignancy sus.

? To look for mediastinal lymphadenopathy

? Ultrasound

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? Abscess?

? Benign vs. malignant

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? Sometimes CT/MRI

? To evaluate for abscess

? EKG/ECHO

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? If suspect Kawasaki Disease

? Biopsy

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? FNA or Excisional
Treatment

Incision drainage with proper evacuation of the

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abscess, followed by anti-tubercular antibiotic

treatment.