Nonbacterial Causes of Lymphangitis With Streaking

Brandon E. Cohen, MD; Arielle R. Nagler, MD; Miriam Keltz Pomeranz, MD


J Am Board Fam Med. 2016;29(6):808-812. 

In This Article

Viral Infections

Herpes simplex virus (HSV) has been reported to cause acute, superficial lymphangitis presenting with lymphangitic streaking. A number of reports of HSV of the upper extremity presenting with lymphatic streaking show no evidence of bacterial superinfection.[3–7] Lymphangitic streaking associated with HSV may present along with systemic symptoms such as fever and lymphadenopathy (LAD), further mimicking bacterial infection.[6,8] In a number of the reported cases, patients were initially misdiagnosed with a bacterial infection and treated with systemic antibiotics.[4,7,8]

Gavelin and Knight[4] reported a case of a nurse who presented with tender, vesicular lesions of the right thumb, lymphangitic streaking, and axillary LAD. The patient was originally treated with erythromycin; however, culture revealed HSV without bacterial infection. Antibiotics were discontinued and the lesions resolved 11 days after the initial presentation. Dorman[3] reported 2 patients presenting with recurrent herpes infection of the hand with superficial lymphangitis. Both patients had similar clinical presentations; however, 1 patient was found to have a bacterial superinfection requiring antibiotics, whereas the other patient was diagnosed with HSV infection alone, highlighting the diagnostic challenge. A patient recently presented at our institution with a recurrent, painful upper extremity bulla associated with a prominent lymphangitic streak. Initial treatment with levofloxacin was unsuccessful and bacterial culture was negative. Skin biopsy suggested occult herpesvirus infection versus a vesicular arthropod reaction. Clinically, herpes simplex infection was favored given the recurrent lesions on the same extremity, lack of insect exposure, history of oral herpes infection, and responsiveness to acyclovir; however, a final diagnosis could not be made with certainty (Figure 1).

Figure 1.

Erythematous patch with central bulla on the ventral forearm, with a lymphangitic streak extending to the antecubital fossa in a patient with herpes simplex virus infection versus a reaction to an arthropod bite. (Photograph obtained by authors at New York University Langone Medical Center in January 2015.)

Eruptions related to herpes zoster have also been described in association with lymphangitic streaking.[7,9] However, clinical presentation and lesion distribution allow a diagnosis of herpes zoster to be more easily distinguished from bacterial lymphangitis compared with HSV. While superficial lymphangitis occurring in the setting of herpesvirus infections is well documented, potential pathogenic mechanisms have not been proposed.