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Lymphangitis, Lymphadenitis, Elephantiasis

1. LYMPHANGITIS

  • Inflammation of lymphatic vessels – manifested by erythematous streaks
  • Often accompanies cellulitis
  • Usually associated with a strep infection – bacteria grow rapidly in the lymphatic system
  • Regional lymphadenopathy is common

Causes

  • Group A β-hemolytic streptococcus infection – most common
  • S. aureus
  • Pseudomonas
  • G negative rods
  • Diabetes, immune deficiency, varicella, chronic steroid use
  • Wuchereria bancrofti – filariasis

Clinical features

  • The primary site is an abscess, infected wound or area of cellulitis
  • Red tender streaks in line of lymphatics – extending from area of cellulitis towards local lymph node
  • Overlying skin is red, accompanies cellulitis
  • Blistering of affected skin
  • Fever
  • Tachycardia

Investigations

  • CBC
  • Blood and pus culture
  • Gram stain

Treatment

  • Penicillin – oral and parenteral
  • Drainage of local nodes
  • Analgesia and NSAIDs
  • Elevation and immobilisation
  • Abscess – surgical drainage

Complications

  • Ulceration and necrosis
  • Bacteraemia, sepsis, death

2. LYMPHADENITIS

  • Inflammation of lymph node

Classification

  • Course
    • Acute
    • Chronic
  • Etiological pattern
    • Microbial – bacterial/mycobacterial, viral, fungal, protozoal
    • Non-microbial – autoimmune, storage disease
  • Histological
    • Follicular – bacterial, HIV, syphilis
    • Paracortical – virus, vaccination, drug hypersensitivity
    • Medullary

Acute suppurative bacterial lymphadenitis

  • Due to S. aureus, Group A strep
  • Acute onset, fever
  • Treated with antibiotics
  • CT/US if it gets worse – to look for phlegmon/abscess/infiltration
    • FNA, surgical irrigation and drainage if abscess present

Subacute lymphadenitis

  • Slower course – over 2-6 weeks
  • No improvement with antibiotics

Tuberculous lymphadenitis

  • Stages of tuberculous lymphadenitis
    • Lymphadenitis →periadenitis → cold abscess → collar stud abscess → sinus

Clinical features

History of patient

  • Fever, malaise, anorexia, myalgia
  • Pain, tenderness of node
  • Sore throat, toothache, ear pain
  • Insect bite, exposure to animal

Physical exam

  • General – febrile or toxic appearing
  • Skin – cellulitis, impetigo, rash
  • ENT – otitis, pharyngitis
  • Lungs – consolidation suggests TB
  • Abdomen – hepatosplenomegaly

Investigations

  • CBC, ESR
  • Throat culture, serology (EBV, CMV, Syphilis, HIV, toxoplasmosis)
  • CXR, CT, MRI, ECG
  • Biopsy – FNA

Treatment

  • Incision drainage with proper evacuation of abscess, followed by antibiotics
    • Anti-tuberculous drugs if TB is implicated

3. ELEPHANTIASIS

  • Enlargement and hardening of limbs or body parts due to tissue swelling
  • Characterised by edema, hypertrophy and fibrosis of skin and subcutaneous tissues due to obstruction of lymphatic vessels
  • Most commonly due to infection by the parasite Wuchereria bancrofti

Etiology

  • Wuchereria bancrofti
  • Vector – Culex mosquito

Pathophysiology

  • Recurrent lymphangitis causes obliteration of lymph nodes → leads to dermal lymphatic backflow → causes edema and recurrent cellulitis → accumulation of protein, growth factors and glycosaminoglycans → formation of protein rich lymphedematous tissue → dermal thickening and proliferation → cracks, ulcerations, fissures → elephantiasis

Clinical features

  • Filarial lymphangitis
  • ↑temperature, profuse sweating
  • Local inflammation and blockage of lymph vessel where adult worm lies
  • Blood exam – microfilaria
  • Brown skin colour
  • Skin ulceration, fibrotic skin tissue
  • Impaired lymphatic drainage
  • Massive leg swelling, pain in testes, thickened skin tissue
  • Verrucous skin appearance

Investigations

  • Identify microfilariae on Giemsa stain – finger prick test (10pm-2am as microfilariae are most active at this time)
  • Puncture enlarged node

Treatment

  • Prevention – use net, long sleeves, mosquito repellent
  • Medical
    • Diethylcarbamazine (DEC)
  • Albendazole
  • Skin washing, elevate and exercise affected body part, lymph drain, compression bandage
  • If inguinal lymph node is affected – treat medically, surgery is not recommended as it may cause fistula
  • If leg affected – in non-advanced case firm bandaging to decrease lymphoedema
    • If advanced, perform excisional operation
      • Charles operation – excision of lymphedematous tissue followed by skin grafting
      • Homan’s operation – raising of skin flaps, excision of lymphedematous tissue and then trimming of skin flaps to required size
    • Physiological operations – omentoplasty, lympho-venous shunt
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