​Kembara Xtra - Medicine - Lymphangitis

​Kembara Xtra - Medicine - Lymphangitis 
Acute or chronic inflammation of lymphatic channels that commonly manifests as red, tender streaks extending (often quickly) to local lymph nodes may be infectious or noninfectious; it frequently affects an extremity as a result of a skin infection that invades the lymphatic vessels; it may also be caused by a compromised lymphatic drainage system as a result of surgery, trauma, or cancer.

Pathophysiology and Etiology 

Acute infection: typically brought on by group A -hemolytic Streptococcus; commonly secondary to lower extremities cellulitis; immunocompromised patients frequently infected with gram-negative bacteria or fungi. Pasteurella multocida and Staphylococcus aureus are the less frequent causes.
Pseudomonas, other Streptococcus species, Aeromonas hydrophila, Bacillus anthracis, Erysipelothrix (fish exposure), Spirillum minus (rat bite disease), other Streptococcus species, and fresh water exposures.
Parapoxvirus (milker's nodule in the workplace)
Lymphogranuloma venereum, a symptom of the Herpes simplex virus
Nodular lymphangitis, sometimes called sporotrichoid lymphangitis, causes swollen lymphatic veins under the skin that may be painful or not. Regional lymphadenopathy may accompany ulcerating lesions.
- Typically does not progress as quickly as acute lymphangitis, and may not exhibit systemic symptoms. - Pathology may reveal granulomas, which are typical of infections caused by Sporothrix schenckii, Nocardia brasiliensis, Mycobacterium marinum, Leishmania sp., Francisella tularensis, and systemic mycoses.
Noninfectious granulomatous lymphangitis is a rare acquired lymphedema of the genitalia in children and may be brought on by sarcoidosis or an unusual form of Crohn's disease.Mosquito bites transfer parasites that cause lymphatic inflammation and dilatation and can predispose to secondary bacterial infection. Filarial lymphangitis is typically brought on by the worm Wuchereria bancrofti, however Brugia malayi and Brugia timori also cause it less frequently. After surgical procedures including lymph node dissection, lymphangitis might develop.
It's unusual to have cutaneous lymphangitis carcinomatosa.
5% of all skin metastases; produced by neoplastic obstruction of dermal lymphatic vessels; breast, lung, stomach, pancreatic, and rectal malignancies are associated.
Swelling around the coronal sulcus of the penis as a result of intense sexual activity or masturbation is known as sclerosing lymphangitis of the penis.

Risk factors include diabetes mellitus, chronic steroid use, peripheral venous catheter use, varicella infection, immune-compromising conditions, human, animal, or insect bites, skin trauma, fungal, bacterial, or mycobacterial skin infections, IV drug abuse, and living in areas where filariasis is endemic.


Prevention 

 Treat underlying causes of persistent lymphedema or reduce it with compression devices.
 Protection against insect bites and arthropod stings  Adequate skin and wound care

Accompanying Conditions 
Tinea pedis (athlete's foot) Sporotrichosis Cellulitis, erysipelas Filarial infection (W. bancrofti) Lymphedema Previous lymph node dissection 

History: Erythematous streaks that can spread in a matter of hours (3); Skin trauma; cuts; abrasions; or fungal infection; Systemic symptoms:
- Fatigue
- Chills and a fever
- Appetite loss
- Migraine
Travel to a tropical area or a location where filariasis is present.

clinical assessment 
Local symptoms can include: erythematous, macular linear streaks from the site of infection toward local lymph nodes; tenderness and warmth over the affected skin or lymph nodes; blistering of the affected skin; fluctuation, swelling, or purulent drainage; nodular lymphangitis can present with subcutaneous swellings along the lymphatic channels; sporotrichosis can present with papulonodular lesions that may ulcerate.

Differential diagnosis: contact dermatitis, cellulitis, erysipelas, thrombus or infection within the thrombosis (septic thrombophlebitis), and allergic reaction, which is less likely to occur if it occurs more than 24 hours after exposure (such as an insect bite). Lymphangitis carcinomatosa is an inflammation brought on by a malignancy.

Laboratory Results: A blood smear may reveal a filarial infection and a CBC may demonstrate leukocytosis.
 Cultures from wounds or blood
FNAC is indicated for filariasis of testiculoscrotal edema but not for other superficial areas. Biopsy or aspiration cultures for nodular lymphangitis. (4) Initial examinations (lab, imaging)
Consider lymphangiography and lymphoscintigraphy for lymphedema instead of plain films.


Other/Diagnostic Procedures
Swab, aspirate, or biopsy the primary location; observe the histology, microscopy, and any purulent discharge from the nodule or distal ulcer.  Blood cultures for systemically sick patients Blood film/smear (e.g., filaria) Serology (e.g., F. tularensis, histoplasma) Lymphangiography or lymphoscintigraphy to detect lymphedema or lymphatic blockage

Lymphedema can be managed by using hot, moist compresses to the affected area, wearing compression clothing, and losing weight.
 Refusal to engage in sexual activity due to sclerosing lymphangitis

Medication: Use empirical treatment for common organisms. Culture and susceptibility should be used to direct antibiotic therapy.
 In cases of minor illness, outpatient oral antibiotics  If there has been no improvement after taking oral antibiotics for 48 hours, reevaluate and consider hospitalization or IV antibiotics.
IV antibiotics if you are seriously ill Treat aggressively with antibiotics and surgery if necrotizing fasciitis is suspected.
Initial Line
group A streptococcal infection antibiotics
Amoxicillin dosage for group A Streptococcus, if known
• Adults
Children under 3 months: 30 mg/kg/day PO divided q12h; Children over 3 months, 40 kg: 25 mg/kg/day PO divided q12h; Children 40 kg: same as adult dosing; Mild to moderate: 500 mg PO q12h; Severe: 875 mg PO q12h; or 500 mg PO q8h; Children under 3 months, 40 kg: 30 mg/kg/day PO divided q12h; Children
- Typical side effects
Diarrhea: Severe side effects
Drug interactions with anaphylaxis, Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN)
 Contraindications for Methotrexate, Venlafaxine, Warfarin, and Hormonal Contraceptives
Penicillin hypersensitivity and dosage information for ampicillin/sulbactam
Children under 40 kg should receive 200 mg/kg/day IV infusion, in divided doses every six hours, with a daily maximum of 8 g of ampicillin. - Common side effects
Serious negative effects include diarrhea and injection site reactions.
 Drug interactions between pseudomembranous enterocolitis and Clostridium difficile diarrhea
 Contraindications for Hormonal Contraceptives
 Hypersensitive responses
Ceftriaxone dosage: adults should take 1 to 2 g IV/IM every 24 hours, while children should take 50 to 75 mg/kg per day IV/IM once daily or in divided doses every 12 hours with a maximum daily dose of 2 g.
 Diarrhea and injection site reactions - Serious side effects
Drug interactions with the same effects as ampicillin or amoxicillin
Do not use the same IV line to deliver calcium-containing solutions.
- Inhibitory conditions
Cephalosporin sensitivity and concurrent IV infusions containing calcium
 Cephalexin - Dosing Adults: 500 mg PO q12h or up to q6h for severe infection or widespread involvement Increased risk of kernicterus, salt precipitation in lungs and kidneys in newborns 28 days (take cefotaxime instead) Children: 25 to 50 mg/kg/day split every 12 hours - Typical side effects
Diarrhea: Severe side effects
Contraindications include SJS, TEN, interstitial nephritis, renal failure, pseudomembranous enterocolitis, and allergy.
Cephalosporin sensitivity Dosing of azithromycin (if allergic to penicillin or cephalosporins)
Adults should take 500 mg PO on day 1 and then 250 mg/day PO on days 2 through 5. Children under 2 years old should take 12 mg/kg/day PO (the maximum dose is 500 mg/day) once daily for five days to treat skin infections in kids. - Typical side effects
 Headache, nausea, vomiting, diarrhea, and abdominal pain - Severe side effects
Drug interactions for prolonged QT, torsade de pointes, liver failure, Lambert-Eaton syndrome, myasthenia gravis, corneal erosion, and anaphylaxis
Nelfinavir, warfarin, and other drugs that may lengthen the QT interval - Contraindications
 Hypersensitivity to macrolide antibiotics (azithromycin, erythromycin, clarithromycin) Hepatic dysfunction or cholestatic jaundice with prior treatment Diethylcarbamazine, ivermectin, albendazole, and doxycycline are used to treat filarial infection.
NSAIDs like ibuprofen or acetaminophen for pain and heat


Surgery may be necessary for the following conditions: Nodular lymphangitis may benefit from I&D; Necrotizing fasciitis necessitates surgical assessment and probably débridement.

Admissions 

Fluids if in hypotensive shock; admit for indicators of acute disease.
Chillers, a fever, and systemic toxicity Discharge on oral antibiotics once systemic symptoms have subsided, followed by IV antibiotics, ICU admission, or surgery, if necessary. Depending on the clinical setting, home IV antibiotics may be a possibility.


Elevate the affected area as a follow-up measure, and observe the improvement for 48 hours.  Investigate recurrent lymphangitis to identify any underlying causes (such as another infectious agent, anatomical anomaly, etc.).
patient observation
close monitoring to guarantee reducing inflammation

Education of Patients 
Teach patients how to properly care for their skin and wounds.


Good prognosis for instances that are not complicated 90% of patients respond well to antimicrobial therapy.
 If untreated, disease, especially group A, can spread quickly.
Streptococcus

Sepsis, cellulitis, necrotizing fasciitis, and myositis are complications.

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