Nodular lymphangitis: a distinctive clinical entity with finite etiologies

Nodular lymphangitis, characterized by inflammatory nodules along the lymphatics draining a primary skin infection, most commonly follows superficial inoculation with Sporothrix schenckii, Nocardia brasiliensis, Mycobacterium marinum, Leishmania (Viannia) panamensis/guyanensis, and Francisella tularensis. Epidemiologic context, clinical presentation, and presumed incubation period help to predict the specific etiologic microorganism. Sporotrichosis, often occurring in gardeners, remains the most recognized cause of nodular lymphangitis. Injuries sustained in marine environments suggest Mycobacterium marinum infection. An incubation time of 1 to 5 days, a painful chancre at the initial lesion site, and prominent tender lymphadenitis strongly implicate tularemia. Frankly purulent discharge from the primary lesion is associated with some infections due to Francisella and Nocardia species. Lesions failing to respond to empirical treatment should usually be biopsied. A detailed history and clues from the physical examination, supplemented by biopsy specimens in selected circumstances, should allow specific therapy for most patients.