NODULAR LYMPHANGITIS - A DISTINCTIVE BUT OFTEN UNRECOGNIZED SYNDROME

Purpose: To describe nodular lymphangitis by reviewing the clinical an d epidemiologic features of this disease with an emphasis on distingui shing specific etiologic agents. Data Sources: English-language articl es were identified through a MEDLINE search (1966 to September 1992) u sing sporotrichosis, lymphangitis, and sporotrichoid as key words; add itional references were selected from the bibliographies of identified articles. In addition, three new patients with nodular lymphangitis a re described. Study Selection: One hundred fifty articles were reviewe d to determine details of the etiologic agents and clinical signs and symptoms of patients with nodular lymphangitis. Data Synthesis: Nodula r lymphangitis develops most commonly after cutaneous inoculation with Sporothrix schenckii, Nocardia brasiliensis, Mycobacterium marinum, L eishmania braziliensis, and Francisella tularensis. The setting in whi ch infection is acquired is useful in differentiating among the variou s organisms causing infection. Sporotrichosis and leishmaniasis can ha ve longer incubation periods than do the other common causes of nodula r lymphangitis. A painful ulcer at the site of the initial lesion sugg ests tularemia; frankly purulent drainage often accompanies infections with Francisella and Nocardia species. Ulcerated or suppurating lymph angitic nodules occur commonly with Nocardia infections. Patients with nodular lymphangitis who fail to respond to empiric treatment for spo rotrichosis should be evaluated for other organisms with appropriate b iopsies and cultures. Conclusions: Nodular lymphangitis has distinctiv e clinical signs and symptoms, most commonly due to infection with a l imited number of organisms. A detailed history, accompanied by informa tion obtained from skin biopsy specimens using appropriate stains and cultures, should allow specific, effective therapy for most of these i nfections.