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Lymphadenitis and streaking not always Streptococci

February 23 2017

A useful summary paper recently published by Brandon Cohen and colleagues from New York reminds us that not all lymphadenitis is streptococcal and may be fungal. Streptococcal lymphadenitis with streaking presents as linear erythema extending proximally towards the regional lymph nodes. It may progress rapidly leading to serious complications including streptococcal toxic shock syndrome and therefore warrants systemic antibiotics. While Streptococcus pyogenes is the commonest bacterial cause of superficial lymphatic vessel inflammation in immunocompetent people, other bacterial and non-bacterial aetiologies can have similar presentations (ie Staphylococcus aureus and Pasteurella multocida). Recognition of these other aetiologies- though challenging- is important to avoid misdiagnosis, delay in administration of appropriate treatments and unnecessary systemic antibiotics.

Lymphangitic streaking, image from Am J Trop Med Hyg. 2014 Dec; 91(6):1263-8. doi: 10.4269/ajtmh.14-0456. Epub 2014 Sep 8.

Non-bacterial causes of lymphangitic streaking includes reports of viral, fungal, iatrogenic and arthropod bite related presentations. Cutaneous and lymphocutaneous fungal infections with aspergillosis and sporothrichosis can cause lymphangitic streaking. Sporotrichosis may present with nodules in the lymph nodes or subcutaneous tissues. Itraconazole or amphotericin B are used to treat these fungal infections.

Herpes zoster and herpes simplex viruses are some of the documented viral causes. Dermatomal lesion distribution is likely to be due to Herpes zoster while pain, vesicle formation, recurrence and failure to respond to antibiotics may suggest herpes simplex. Arthropod bites may cause lymphangitis either through toxin injection or hypersensitivity reaction.  Ticks and spiders of the species Loxosceles are some of the documented offenders. In general, insect bites do not lead to lymphadenopathy or systemic symptoms. They also respond to antihistamines and /or short course oral steroids.

Topical application of cartharidin for treatment of warts and subcutaneous injections of BCG vaccine and Purified Protein Derivative (PPD) are some of the reported iatrogenic causes of lymphangitic streaking.

Topical application of cartharidin for treatment of warts and subcutaneous injections of BCG vaccine and Purified Protein Derivative (PPD) are some of the reported iatrogenic causes of lymphangitic streaking.

Link to paper