Acute Lymphangitis

Acute lymphangitis is rapid onset inflammation of lymphatic channels with systemic upset. In Kenya, acute bacterial lymphangitis from streptococci and staphylococci is the commonest cause, and acute attacks of lymphatic filariasis (acute dermatolymphangioadenitis) occur in the coastal belt.

• Entry points: skin breaks in the foot, hand or leg; tinea pedis; cuts; insect bites.
• Repeated episodes damage lymphatics and lead to lymphoedema.

Sudden fever with rigors, headache and malaise, then a hot red tender streak spreading proximally from a wound with painful enlarged regional nodes.

• Filarial attack: retrograde (centrifugal) spread of inflammation down the limb, fever, painful nodes, with later lymphoedema or hydrocele.
• Differential diagnosis: thrombophlebitis, cellulitis, erysipelas, nodular lymphangitis, tularaemia, cat scratch disease, deep vein thrombosis, podoconiosis attack, insect bite reaction, gout.
• Complications: septicaemia, abscess, recurrent attacks with chronic lymphoedema and elephantiasis, secondary skin infection, shock.

Clinical, with tests to find the cause.

• Full blood count, CRP, blood cultures; swab of wound; glucose, HIV test.
• In endemic areas: night blood film (microfilariae), circulating filarial antigen test, ultrasound of lymphatics (filarial dance sign).
• Duplex ultrasound if venous thrombosis is possible.

Antibiotic treatment and limb care; filarial disease needs antifilarial therapy and hygiene.

• Supportive: rest, limb elevation, cool compresses, analgesia (paracetamol 1 g, ibuprofen 400 mg), meticulous skin hygiene (wash twice daily with soap and water, dry between toes), treat entry lesions, wear shoes.
• Pharmacological: flucloxacillin 500 mg to 1 g four times daily for 7 to 10 days (penicillin V 500 mg four times daily; clindamycin 300 to 450 mg three times daily if allergic). Severe or systemic: benzylpenicillin 1.2 to 2.4 g IV every 6 hours with flucloxacillin 1 to 2 g IV every 6 hours. Filarial lymphatic disease: doxycycline 200 mg daily for 4 to 6 weeks, or albendazole 400 mg twice daily for 3 weeks, or diethylcarbamazine 6 mg/kg daily for 12 days after excluding onchocerciasis and loiasis; mass treatment is albendazole 400 mg with diethylcarbamazine 6 mg/kg single dose annually. Prophylaxis for recurrent bacterial attacks: benzathine benzylpenicillin 1.2 million units IM every 3 to 4 weeks or penicillin V 250 to 500 mg twice daily.
• Procedures: drainage of abscess; lymphoedema management with compression and exercise; hydrocele surgery.
• Special groups: pregnancy, give flucloxacillin or penicillin and delay antifilarial drugs; children, weight based doses; HIV, culture if there is no response; diabetes, close monitoring.
• Red flags: hypotension, confusion, spreading necrosis, severe pain, fever beyond 48 hours, recurrent attacks every few months.
• Follow-up: review at 48 to 72 hours; refer recurrent attacks for lymphoedema care; community treatment of filariasis.