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

Arthropod Bites

Noninfectious lymphangitic streaking may also occur after bites from various insects, ticks, and spiders.[2,18–22] In general, lymphangitic streaking associated with an insect bite has not been reported to present with systemic systems or LAD.[2,18,20,21] The mechanism of lymphangitis is proposed to be secondary to either a hypersensitivity reaction or toxin injection.[2,18,23,24] Certain patient populations, such as those with hematologic abnormalities, have a greater tendency to develop exaggerated responses after arthropod bites. For instance, it has been well described that patients with chronic lymphocytic leukemia tend to develop exaggerated responses to arthropod bites, which manifest as vesicles or bullae with prominent edema and erythema that may be accompanied by lymphadenopathy and lymphangitic streaking[25–27] (Figure 2). Patients with lymphangitic streaking associated with an uncomplicated arthropod bite can be successfully managed with antihistamines and/or topical or oral steroids.[20,23,24]

Figure 2.

Two annular patches with surrounding erythema associated with lymphangitic streaks that developed after insect bites on the medial thigh of a patient with chronic lymphocytic leukemia. (Photograph obtained by authors at New York University Langone Medical Center in July 2013.)

In 1 case, a pediatric patient presented with prominent erythematous streaks extending from a lesion on the central abdomen toward the bilateral axilla, resembling a V shape. Dermoscopy of the initial macule at the vertex of the lesion revealed a hemorrhagic center and crusted punctum, suggesting an insect bite.[20] In another case a patient presented with a pruritic lesion on the distal upper extremity that progressed to a red, tender linear streak extending toward the axilla. The pigeon tick (Argas reflexus) was recovered from the site and identified. The patient was treated with antihistamines and oral steroids, and the lesion resolved within 5 days.[19]

Spider bites, notably from those of Loxosceles species, are another cause of lymphangitic streaking that can occur without associated bacterial infection. Wright and colleagues[22] performed a retrospective study of patients with suspected bites from Loxosceles reclusa, commonly known as the brown recluse spider. In this series, among 8 patients who required hospitalization, 2 presented with lymphangitic streaking extending from the location of the bite. In another case a pediatric patient presented with a bite on the abdomen from the brown spider Loxosceles arizonica. Lymphangitic streaks were observed extending from the bite superiorly toward the right axilla and inferiorly to the right inguinal area. Systemic systems and LAD were absent. The patient was successfully managed with a 4-day course of prednisone.[23]