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General Considerations
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Lymphangitis and lymphadenitis are common manifestations of a bacterial infection that is usually caused by hemolytic streptococci or staphylococci (or by both organisms) and usually arises from an area of cellulitis, generally at the site of an infected wound The wound may be very small or superficial, or an established abscess may be present, feeding bacteria into the lymphatics The involvement of the lymphatics is often manifested by a red streak in the skin extending in the direction of the regional lymph nodes, which are, in turn, generally tender and engorged Systemic manifestations include fever, chills, and malaise The infection may progress rapidly, often in a matter of hours, and may lead to septicemia and even death
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Treatment
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Though empiric therapy for neoplasm is occasionally warranted, the clinician should be aware of benign causes, especially histoplasmosis Urgent treatment for neoplasm consists of (1) cautious use of intravenous diuretics and (2) mediastinal irradiation, starting within 24 hours, with a treatment plan designed to give a high daily dose but a short total course of therapy to rapidly shrink the local tumor even further Intensive combined therapy will palliate the process in up to 90% of patients In patients with a subacute presentation, radiation therapy alone usually suffices Chemotherapy is added if lymphoma or smallcell carcinoma is diagnosed Balloon angioplasty of the obstructed caval segment combined with stent placement provides prompt relief of symptoms and is the procedure of choice Long-term outcome is complicated by risk of re-occlusion from either thrombosis or further growth of neoplasm Surgical procedures to bypass the obstruction are complicated by bleeding relating to high venous pressure In cases secondary to mediastinal fibrosis or pericardial constriction, surgical excision of the fibrous tissue around the great vessels may reestablish flow but is a substantial operative procedure in an often acutely ill patient
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Clinical Findings
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A Symptoms and Signs
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Throbbing pain is usually present in the area of cellulitis at the site of bacterial invasion Malaise, anorexia, sweating, chills, and fever of 378 40 C develop rapidly The red streak, when present may be definite or may be very faint and easily missed, especially in dark-skinned patients It is usually tender or indurated in the area of cellulitis The involved regional lymph nodes may be significantly enlarged and are usually quite tender The pulse is often rapid
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Prognosis
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The prognosis depends on the nature and degree of obstruction and its speed of onset Slowly developing forms secondary to fibrosis may be tolerated for years A high degree of obstruction of rapid onset secondary to cancer is often fatal in a few days or weeks because of increased intracranial pressure and cerebral hemorrhage, but treatment of the tumor with radiation and chemotherapeutic drugs may result in significant palliation Balloon angioplasty and stenting provides good relief but may require re-treatment for recurrent symptoms secondary to thrombosis or restenosis
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Rice TW et al The superior vena cava syndrome: clinical characteristics and evolving etiology Medicine (Baltimore) 2006 Jan;85(1):37 42 [PMID: 16523051] Wilson LD et al Clinical practice Superior vena cava syndrome with malignant causes N Engl J Med 2007 May 3;356(18): 1862 9 [PMID: 17476012]
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B Laboratory Findings
Leukocytosis with a left shift is usually present Later, blood cultures may be positive, most often for staphylococcal or streptococcal species Culture and sensitivity studies of the wound exudate or pus may be helpful in treatment of the more severe or refractory infections but are often difficult to interpret because of skin contaminants
Differential Diagnosis
Lymphagitis may be confused with superficial thrombophlebitis, but the erythema and induration of thrombophlebitis is localized in and around the thrombosed vein Venous thrombosis is not associated with lymphadenitis, and a wound of entrance with secondary cellulitis is generally absent Superficial thrombophlebitis frequently arises as a result of intravenous therapy, particularly when the needle or catheter is left in place for more than 2 days; if bacteria have also been introduced, suppurative thrombophlebitis may develop Cat-scratch fever should be considered when lymphadenitis is present; the nodes, though often very large, are relatively nontender Exposure to cats is common, but the patient may have forgotten about the scratch It is extremely important to differentiate cellulitis from acute streptococcal hemolytic gangrene, necrotizing fascitiis, gram-negative anaerobic cutaneous gangrene, and progressive bacterial synergistic gangrene These are deeper infections that may be extensive and are potentially lethal
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