NODULAR LYMPHANGITIS - A DISTINCTIVE BUT OFTEN UNRECOGNIZED SYNDROME

Purpose: To describe nodular lymphangitis by reviewing the clinical and epidemiologic features of this disease with an emphasis on distinguishing specific etiologic agents. Data Sources: English-language articles were identified through a MEDLINE search (1966 to September 1992) using sporotrichosis, lymphangitis, and sporotrichoid as key words; additional references were selected from the bibliographies of identified articles. In addition, three new patients with nodular lymphangitis are described. Study Selection: One hundred fifty articles were reviewed to determine details of the etiologic agents and clinical signs and symptoms of patients with nodular lymphangitis. Data Synthesis: Nodular lymphangitis develops most commonly after cutaneous inoculation with Sporothrix schenckii, Nocardia brasiliensis, Mycobacterium marinum, Leishmania braziliensis, and Francisella tularensis. The setting in which infection is acquired is useful in differentiating among the various organisms causing infection. Sporotrichosis and leishmaniasis can have longer incubation periods than do the other common causes of nodular lymphangitis. A painful ulcer at the site of the initial lesion suggests tularemia; frankly purulent drainage often accompanies infections with Francisella and Nocardia species. Ulcerated or suppurating lymphangitic nodules occur commonly with Nocardia infections. Patients with nodular lymphangitis who fail to respond to empiric treatment for sporotrichosis should be evaluated for other organisms with appropriate biopsies and cultures. Conclusions: Nodular lymphangitis has distinctive clinical signs and symptoms, most commonly due to infection with a limited number of organisms. A detailed history, accompanied by information obtained from skin biopsy specimens using appropriate stains and cultures, should allow specific, effective therapy for most of these infections.