Clinical features in the immunocompetent patient:
(1) inoculation site, typically on an extremity - abrasian, puncture, bite, etc.
(2) local infection at the inoculation site, followed by the appearance of secondary nodules and ulcerations running along the lymphatics that drain the inoculation site
(3) lymphadenopathy along the affected lymphatic vessels
The infection may progress to a systemic infection in a patient with impaired host defenses.
Common organisms showing a nodular lymphangitis:
(1) Sporothrix schenckii
(2) atypical Mycobacteria, especially Mycobacterium marinum
(3) Nocardia brasiliensis or Nocardia species (N. asteroides, N. nova, etc)
(4) Leishmania brasiliensis
Fungus:
(1) Blastomyces dermatitidis
(2) Histoplasma capsulatum
(3) Coccidioides immitis
(4) Cryptococcus neoformans
(5) Scedosporium apiospermum
(6) fungi associated with chromomycosis
Bacteria:
(1) Streptococcus pyogenes
(2) Francisella tularensis (tularemia)
(3) Burkholderia (Pseudomonas) pseudomallei
(4) Bacillus anthraxis
Virus:
(1) Vaccinia (cowpox)
Evaluation of the patient:
(1) Collect a complete occupational, travel and recreational exposure history.
(2) Perform appropriate cultures (including for acid fast bacilli and fungi). Hold aerobic cultures for several days to detect slow growing organisms.
(3) Do not become distracted by bacteria causing secondary infection.
(4) Biopsy for culture and histologic examination may be helpful for making the diagnosis.
