[Diagnostic image (294). A man with a painful, red, swollen finger]

A 35-year-old man presented with a tendineal panaritium and lymphangitis of his arm caused by a group A beta-haemolytic streptococcal infection after an accidental splinter injury.

[Clinical features and diagnosis of pulmonary lymphangitic carcinomatosis]

BACKGROUND & OBJECTIVE

Pulmonary lymphangitic carcinomatosis (PLC) is a special type of pulmonary metastasis of carcinoma. It is easy to be misdiagnosed as other pulmonary interstitial diseases. This study was to discuss the clinical features of PLC, and provide experience information for diagnosis, differentiated diagnosis, and evaluation of prognosis of PLC.

METHODS

A retrospective comparison analysis was performed on 43 PLC patients with pathologic diagnosis and 46 patients with other pulmonary interstitial diseases with clear etiology in the first affiliated hospital of Sun Yat-sen University within the past decade.

RESULTS

In PLC group, 20 patients were found with primary lung cancer; 23 patients were found with primary non-pulmonary carcinoma: 9 cases of breast cancer, 8 cases of large intestinal carcinoma, and 6 cases of gastric carcinoma. The changes of imaging included linear and radiating appearances from the hilum to the outer part even extending to the pleura with nodules, ground-glass opacity of the lung. Enlargement of lymph nodes in mediastinum was present in 51.2% (22/43) and that in pleural effusion was present in 53.5% (23/43) of patients. Extrapulmonary manifestations (metastasis) included 19 cases (44.2%) of lymph nodes to the supraclavicular region, axillary fossa, and post-peritoneal region, 15 cases (34.9%) to the pleura, 9 cases (20.9%) to the bones, 6 cases (14.0%) to the liver, 3 cases (7.0%) to the pericardium, and 3 cases (7.0%) to the brain. The elevated serum level of CEA was commonly observed (23/43, 53.5%). Respiratory manifestations of PLC, such as coughing, panting, dyspnea, and so on, could not be cured by anti-spasm treatment. The development of PLC was so progressive that 31 patients (72.1%) were followed for only 2-7 months before death. The changes of imaging in other pulmonary interstitial disease group included irregular linear or reticular appearances, enlargement of lymph nodes in the mediastinum and hilum, and extrapulmonary manifestations like pleural effusion were not observed. Respiratory manifestations, such as coughing, panting, dyspnea, and so on, could be cured by anti-spasm treatment. Moreover, the development of PLC was relatively slow.

CONCLUSIONS

PLC often occurs in patients with primary carcinoma in lung, breast, large intestine, stomach, and so on. More attention should be paid to the diagnosis of PLC in patients who have pulmonary interstitial lesions as described above, and whose respiratory symptoms could not be relieved by anti-spasm treatment and developed progressively. The prognosis of PLC is poor.

Histofarcin test for the diagnosis of epizootic lymphangitis in Ethiopia: development, optimisation, and validation in the field

Histofarcin, a skin test antigen for the diagnosis of epizootic lymphangitis, was locally produced from the mycelial form of Histoplasma capsulatum var. farciminosum (HCF) in disease-endemic districts of Ethiopia and tested for its application in the field between April 2002 and May 2003. The test was evaluated using 108 mules, 84 in endemic and 24 in disease-free districts. Microscopic and mycological examinations of clinical lesions were used as the "gold standard" for the validation of the test. The concentration of histofarcin that caused an optimum reaction was 0.2-0.4 mg/mL in a 0.1 mL dose and this was attained 24-48 h post-injection. The sensitivity and specificity of the histofarcin test were 90.3% (CI = 73.1, 97.5) and 69% (95%, CI = 48.1, 84.9%) in disease-endemic districts. On the other hand, specificity was 100% (CI=94.8, 100) in disease-free districts. Positive and negative predictive values of the histofarcin test were 77.78% (95% CI = 60.4, 89.3) and 85.71% (95% CI = 62.6, 96.2), respectively. A marginal substantial agreement (kappa = 0.61, P = 0.0000) was observed between the clinical status and the result of the histofarcin test. A large proportion (31%) of 'false positives' was recorded in endemic districts, which could be due to the pre-clinical stage of the disease. The latter ended in lower specificity and positive predictive value of the test since the true infection status of a 'false positive' could not be known on the basis of clinical features. Therefore, standard test validation procedures including slaughtering and isolation of HCF is required. After proper validation, we conclude that the histofarcin test could play a significant role in detecting early infection, and differentiating of EL from glanders, ulcerative lymphangitis, and sporotrichosis.

[Nonvenereal sclerosing lymphangitis of the penis: presentation of a clinical case]

Nonvenereal sclerosing lymphangitis of the penis is an infrequent process that affects the distal lymphatics of this organ. It is characterized by the sudden appearance of a translucent and indurated cord on the coronal sulcus. Its etiology is unknown, although it has been related to microtraumas in the area after intense sexual activity. It is a benign, self-resolving process, so it is not necessary to perform a biopsy in early stages, and initial treatment should be conservative. We present a new case of this disease and discuss its etiopathogenic, clinical, diagnostic and therapeutic characteristics.

Asymptomatic lymphangitis carcinomatosis due to squamous cell lung carcinoma

Lymphangitis carcinomatosa most commonly due to primary malignancy originating in the breast, stomach, pleura and prostate but may also originate from the lung itself. It is clinically characterised by progressing dyspnoea with or without cough even at an early stage. We report the case of a patient with squamous cell lung cancer presenting with asymptomatic lymphangitis carcinomatosa.

Two cases of acute respiratory failure due to carcinomatous lymphangitis in HIV patients

In HIV-infected patients, acute respiratory failure is usually due to infectious pneumonia. In this report, we describe two cases of acute respiratory failure in HIV patients with clinical presentation suggesting infectious pneumonia. In both cases, the clinical condition deteriorated and death occurred after several days despite therapy. In both cases bronchial biopsies confirmedbronchogenic carcinoma responsible for carcinomatous lymphangitis.

Squamous cell carcinoma of the cervix presenting as lymphangitic carcinomatosis: a case report and review of the literature

BACKGROUND

Lymphangitic carcinomatosis (LC) secondary to carcinoma of the cervix is rare. The presenting symptoms are misleading and nonspecific, which often leads to delayed diagnosis.

CASE

We present the case of a 24-year-old woman with dyspnea and lower back pain, who was found to have stage IIIb squamous cell carcinoma of the cervix complicated by pulmonary LC.

CONCLUSIONS

Pulmonary LC is a rare but important manifestation of metastatic cervical cancer. Patients present with severe respiratory compromise, which mimics other, more common disease states. Diagnosis can be achieved by transbronchial biopsy. Optimal treatment of the patient with LC is not well defined, but a trial of chemotherapy and/or intravenous steroids may be warranted. Prognosis for this condition is poor.

Lymphangitis carcinomatosis of unknown origin presenting as severe pulmonary hypertension

An apparently healthy 46-year-old woman was admitted because of progressive shortness of breath that had begun 2 months before her admission. Physical examination revealed a patient with respiratory distress, tachycardia, and mild jugular venous distention; otherwise, results were unremarkable. Our investigation revealed hypoxia and severe pulmonary hypertension with signs of right heart dysfunction, but no primary cause was found. The patient died 5 days after admission. Autopsy revealed pulmonary lymphangitis carcinomatosis caused by papillary carcinoma. No primary tumor was found.

Kikuchi-Fujimoto lymphadenitis

Kikuchi-Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, was initially described as a distinct histologic pattern of lymphadenitis generally associated with a benign self-limited clinical course. While most common in Southeast Asia, where KFD was initially described in 1972 in young women, this lesion has since been reported in patients of virtually any age, gender, or ethnic background from a variety of geographic locations, including the United States. In addition, cases showing extranodal involvement have been described. The spectrum of clinical and histologic features associated with this disorder suggest that KFD more likely represents a common pattern of response to a variety of etiologic factors rather than a single clinicopathologic entity. In this review, the characteristic clinical, laboratory, histologic, and immunophenotypic features of this disorder are described, with emphasis on differential diagnosis with other types of necrotizing lymphadenitis and with malignant lymphoma. Unusual clinical presentations and features of disease when present at extranodal sites are also reviewed.

[Some clinical and radiographic features of tuberculosis in young adults and its early diagnosis]

Clinical and X-ray findings were analyzed in 123 patients aged 18-35 years who suffered from primary tuberculosis. Adenopathy was infrequently encountered and in most patients it appeared as multiple pulmonary forms. Some specific features were revealed. There were seldom limited processes and predominantly exudative and necrotic forms involving mainly the lower lobe. The characteristic features were the frequent involvement of the sixth segment of one or two lungs in the process and the upper-lobar tuberculosis. In 79.7% of the examinees, areas of tuberculous lymphangitis were defined, which preceded the process in some patients or accompanied it or were identified after resorption of parenchymatous changes in other patients. The above specific features of pulmonary processes may be useful for early diagnosis of primary diagnosis in young adults.

[Non-venereal sclerosing lymphangitis of the penis. Report of two clinical cases]

Nonvenereal sclerosing lymphangitis of the penis is a rare condition that preferably affects men aged between 20 and 40 years, and it is appeared like a hard cord or a nodular lesion in the sulcus coronarius penis. It is believed that it has origin in lymph vessels of the penis. Usually it is resolved in a self-limited way, so the initial treatment is conservative. We report two cases, and some etiopathogenic, diagnosis and therapeutic aspects are discussed.

Acute lymphangitis mimicking mechanical neck pain

OBJECTIVE

To discuss acute lymphangitis as a potentially serious infection that can mimic mechanical musculoskeletal pain.

CLINICAL FEATURES

A 27-year-old male plant worker had right-sided neck pain. Numerous lesions on the patient's scalp were observed, but were not considered to be related to the chief complaint.

INTERVENTION AND OUTCOME

Conservative therapy was initiated to address what was thought to be mechanical neck pain. Shortly after the initial visit, it became evident that the source of the neck pain was infection because lymphangitis developed. Antibiotic therapy was initiated and complete resolution of the complaint occurred within 1 week.

CONCLUSION

Primary contact practitioners should consider all aspects of the patient history and physical findings when formulating a diagnosis. This is especially important in the case of patients presenting with lymphangitis because mismanagement could have serious consequences. The importance of a good patient history and team approach to care is demonstrated by this case.

Carcinomatous lymphangitis mimicking pulmonary thromboembolism

A 41-year-old woman was admitted with rapidly worsening dyspnea. Echocardiography disclosed interventricular septal flattening and a markedly decreased left ventricle, although left ventricular contraction remained normal. Computed tomography of the chest demonstrated slightly dilated main pulmonary arteries and fine reticulonodular densities in the lung. Examination of a transbronchial lung biopsy specimen revealed carcinomatous lymphangitis, and the patient died 7 days after admission. The clinical presentation of this patient was difficult to discriminate from that seen with pulmonary thromboembolism.

[Paraneoplastic thrombosis of subclavian and right internal jugular veins. Clinical case]

A clinical case of the "Paraneoplasic thrombosis of subclavian vein and right internal jugular vein", is presented at a young patient, with right lung carcinomatous lymphangitis, clinically confirmed by BAL with probable prostatic point of start.

Nodal and nonnodal inflammatory processes of the pediatric neck

In the pediatric neck, inflammatory processes are common and usually are nodal in origin. Virtually every pediatric infection, including viral diseases, can result in dramatic cervical adenopathy. The differential diagnosis for a dominant pediatric node, however, is different from that in adults, with neoplastic disease occurring less frequently. When nonnodal cervical infections or abcesses occur, it is important to identify the source and involvement of major vessels, the airway, and the mediastinum. This article reviews common nodal processes and the complications of suppurative adenopathy. Nodal and nonnodal inflammatory processes are discussed, with emphasis on the clinical presentation and common imaging findings.

Pulmonary lymphangitic sarcomatosis from cutaneous angiosarcoma: an unusual presentation of diffuse interstitial lung disease

Pulmonary lymphangitic sarcomatosis (PLS) is not much recognized clinically although it shows similar pathological patterns and diagnostic features to pulmonary lymphangitic carcinomatosis (PLC). We report a case with hand angiosarcoma whose chest X-ray findings revealed a diffuse interstitial pattern consistent with lymphangitic spreading. The final diagnosis was made by open lung biopsy. The clinical, diagnostic and pathological features of this disease process are reviewed.

Epizootic lymphangitis in horses: a review of the literature

Epizootic lymphangitis is a relatively common infectious disease of horses and other liquids in certain parts of the world. The infection rate varies according to the geographic area and the age of the animal. The disease is most commonly characterised by a cord-like appearance of the subcutaneous lymphatic and cutaneous pyogranulomas, the discharge from which contains spherical or pear-shaped bodies of the causal agent, Histoplasma farciminosum. Diagnosis can be made by the demonstration of typical organisms in stained smears, culture and tissue sections. Serological tests and a skin hypersensitivity test have been described. Amphotericin B is the drug of choice for the treatment of clinical cases. An attenuated vaccine and a killed formalized vaccine are available and can be used in endemic areas to control the disease.

[Carcinomatous lymphangitis]

DEFINITION

Carcinomatous lymphangitis is a radioclinical entity accounting for about 8% of all cases of lung metastasis defined as the presence of tumoral cells in lymph vessels and lung interstitium.

DIAGNOSIS

Biopsy specimens or bronchial brushings obtained by fibroendoscopy or bronchioalveolar lavage fluid usually reveal adenocarcinoma.

PRACTICAL MANAGEMENT

In clinical practice, the patient presents with dyspnea and non-specific infiltration on the chest x-ray. The clinical situation worsens rapidly. Millimetric CT-scan shows highly suggestive polygonal images in the subpleural area. Respiratory function tests may be helpful for the differential diagnosis, particularly in difficult cases, showing a mixed ventilation disorder without altered carbon monoxide diffusion and hypoxemia at rest without hypercapnia.

SEARCH FOR THE PRIMARY CANCER

Primary lesions must be identified for specific treatment. Pathology findings help guide the search. Despite the highly unfavorable prognosis (median survival = 3 months), etiological treatment when possible can improve quality of life and possibly survival. Symptomatic treatment is indicated and must be adapted to each individual case.

Comparison of high resolution CT findings of sarcoidosis, lymphoma, and lymphangitic carcinoma: is there any difference of involved interstitium?

PURPOSE

The purpose of this study was to determine distinguishing features of three diseases that are distributed along the lymphatics.

METHOD

CT scans of 40 patients with lymphangitic carcinomatosis, 41 with sarcoidosis, and 44 with malignant lymphoma were retrospectively reviewed. We evaluated the degree of involvement of the interlobular septa, bronchovascular structures, subpleural interstitium, and other CT findings.

RESULTS

The number of thickened interlobular septa and the extent of involvement of the subpleural interstitium in lymphangitic carcinomatosis were higher than those in sarcoidosis and malignant lymphoma (p<0.0001). Nodules of >1 cm in diameter were more often seen in malignant lymphoma (41.0%) than in the other two diseases (p < 0.001). Bilateral distribution was more common in sarcoidosis (100%) than in the others (p<0.001).

CONCLUSION

The major difference among lymphangitic carcinomatosis, sarcoidosis, and malignant lymphoma is the greater involvement of the interlobular septa and subpleural interstitium in lymphangitic carcinomatosis than in either sarcoidosis or malignant lymphoma.

Lymphocutaneous syndrome. A review of non-sporothrix causes

The lymphocutaneous syndrome can be caused by a number of diverse microorganisms requiring very different antimicrobial therapy for resolution. The epidemiology and geographic occurrence of the infection often can provide important first clues to the microbiologic etiology. Accurate diagnosis can be accomplished usually by punch or wedge biopsy of a primary lesion or proximal subcutaneous nodule submitted for histopathologic examination and culture. The microbiology laboratory staff should be alerted to the diagnostic possibilities so that appropriate cultural and incubation techniques, procedures, and precautions can be initiated. Provision of a correct microbiologic diagnosis and institution of appropriate antimicrobial therapy will result in a complete cure in almost all instances. Adjunctive surgical debridement may be required for certain organisms such as Nocardia or Mycobacterium chelonae.

[Pulmonary lymphangitic carcinomatosis]

OBJECTIVE

To explore the clinical manifestations of pulmonary lymphangitic carcinomatosis (PLC), to analyse its associated diagnostic methods, and to improve the understanding of PLC and its diagnosis.

METHOD

Retrospective analysis of 4 cases of PLC and review of the literature.

RESULT

The clinical manifestations of PLC include: (1) dyspnea and cough; (2) normal or restrictive pattern ventilation; (3) diffuse or local reticulonodular infiltrates in the lung like interstitial fibrosis and pleural effusion on chest radiograph; (4) CT and high-resolution CT (HRCT) scans reveal a beaded chain appearance caused by uneven thickening of the interlobular septa and pleural membrane, polygonal thickening of bronchovascular bundles, and mediastinal lymphadenopathy as well.

CONCLUSION

These clinical data suggest that any manifestations similar to pulmonary interstitial fibrosis complicated with pleural effusion and paratracheal lymphadenopathy should be further differentiated from PLC by HRCT and pleural-lung tissue biopsy.