Joachim Zuther, Lymphedema Specialist. 
There are numerous reasons why patients with lymphedema are at an increased risk for infections. Normally the body is protected by a fine acid layer on the surface of the skin, which prevents bacteria and other pathogens from entering. However, the skin in lymphedema tends to be dry and scaly, causing a disruption of the protective acid layer, or if deepened skin folds are present, moisture collecting in these folds may create a breeding ground for bacteria. The fact that the swelling present in lymphedema causes a disruption of the local immune defense in the affected tissues further complicates this situation. Once bacteria are able to enter lymphedematous tissue, protein and accumulated waste products present in lymphedema provide an ideal breeding ground for infection. Due to the swelling, even in minimal lymphedema, the body’s natural defense cells may not be able to fight these invaders sufficiently.
The initial onset of lymphedema, as well as the worsening of present lymphedema is frequently associated with the occurrence of infections. It is thought that these infections result in increased fibrosis of lymph vessels and lymph nodes, thus further complicating lymphedema.
Common infections include:
Cellulitis
This is an acute infection of the skin and deeper tissues characterized by painful swelling, redness of the skin, and heat. Cellulitis is frequently caused by streptococcus (sometimes staphylococcus) bacteria, which enter the tissues through the skin via cuts, abrasions or breaks. These bacteria are present in the normal skin flora and do not cause an infection while on the skins outer surface.
Cellulitis may become life threatening when it spreads via the lymphatic or blood system to vital organs and other body parts (Lymphangitis).
Erysipelas
This acute dermal infection is also caused by streptococcus bacteria and affects the skin and tissues located just underneath the skin, to include lymphatic vessels and nodes.
Erysipelas is one of the most common infections in lymphedema and tends to recur. Typical for this infection is its rapid onset accompanied by fiery red edema with raised and distinct margins in the affected area, and its rapid spreading through superficial lymph vessels, which contributes to the formation of fibrosis in the affected tissues.
Typical symptoms include swelling, redness, fever, headache, sometimes vomiting and chills.
Lymphangitis
Lymphangitis is an infection of the lymphatic vessels and most often results from an acute streptococcal infection of the skin, which is often associated with cellulitis. Less frequently it results from a staphylococcal infection. The infection may spread to the blood stream causing a potentially life threatening emergency. Symptoms include red streaks from the infected area to the armpit or groin, fever, pain, headache and enlarged lymph nodes.
What to Do in Case of an Infection
Do not wait, and do not ignore any sign of an infection!
Seek immediate medical treatment to prevent further complications!
Individuals who are at a high risk for lymphedema must remain alert to the signs of infection as these symptoms are often the first signs of the onset of lymphedema. In such cases, quick intervention may help to delay the onset of lymphedema as well as prevent the infection. The problem may aggravate and become potentially life threatening if timely care is not taken.
Treatment: Antibiotics should be administered as soon as possible; penicillin-based medications are used either orally, if no systemic infection is present, or by intra-venous application. Oral penicillin is administered for a minimum of 14 days, or until the inflammation has been resolved. In some patients it may take one or two months of therapy for symptoms to completely resolve. Other antibiotics may be used in cases of penicillin allergy (clindamycin or claritromycin). In severe cases hospitalization may be necessary.
Lymphedema patients with a history of recurrent infections should have a two-week supply of antibiotics on hand, particularly while traveling.
Manual Lymph Drainage should be suspended during episodes of acute infection and fever. In order to prevent excessive swelling, light compression should be applied during these episodes if tolerated.
Added November 2, 2010: Consensus Document of the British Lymphology Society on the Management of Cellulitis in Lymphedema
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Thank you for publishing this and other information… I have had cellulitis 4 times and was hospitalized on first episode (when I didn’t realize severity of situation, so didn’t get to emergency room immediately).Now I take prophylactic penicillin (monthly injections). Your information is important and very accurate from my experience.
Hello,
Can you please give me more information about “prophylactic penicillin”? My legs are chronically red & dry and I don’t know if this is related to an infection or not. Unfortunately my PCP isn’t very familiar with my diagnosis of RSD and the accompanying lymphedema. Thank you!
Dear Charlie:
The dosage in terms of prophylactic antibiotics (usually broadspectrum) depends on your personal situation. I would like to refer you the Consensus Document of the International Society of Lymphology (ISL) on the teatment of peripheral lymphedema (http://www.u.arizona.edu/~witte/2003consensus.pdf). The topic of antibiotics is covered on page 7. I would suggest to bring the print-out with you during your next visit with the PCP.
Kind regards,
Joe
Hello Joe,
Do we know what part inflammation and autoimmune response play in a cellulitic attack? Typical bacterial infections yield to antibiotics after 3-5 days, but the usual course required for a lymphedmatous limb is much longer. I’ve read that an antibiotic with anti-inflammatory properties, or a separate anti-inflammatory is indicated to treat cellulitis.
Dear Bob:
In lymphedema the autoimmune response is typically delayed – compared to non-swollen tissues – due to the accumulation of water and protein in the subcutaneous tissue spaces, and consequently increased distance between blood vessels and tissue layers. This makes it more difficult for defense cells to reach areas affected by the infection. I will do some reseach on the second part of your question and get back to you as soon as I know more.
Dear Bob:
I believe the second part of your question earlier is answered in the Consensus Document of the British Society of Lymphology on the Management of Cellulitis in Lymphedema. Here is the link:
http://www.lymphoedema.org/Menu3/consensus_on_cellulitis_aug_10.pdf
I had been infection free since last December thanks to prophylactic 500 mg Penecilin BID. That was the logest reprieve I have had in 20 years. On a Monday 3 weeks ago I went to my PCP (an infectious disease specialist)to get a flu short and a medicine changed and I said “something doesn’t feel right in my legs.” He unfortunately poo pooed it. By Thursday my legs were not a pretty site turning quite red. But it was not a full blown episode so I hung in. That night my temp went to 101.8. Saturday morning I called the doctor and told him “It’s not the worst infection I have ever had by I want to stop it before it becomes a major disaster.” He put me in the hospital. IV antibiotics and he kept me totally off the legs, elevate them and hang in there.
To make a long story short, my commercial insurance carrier is not approving my hospitalization so far. (That is under appeal.) But the company wanted to put me into a rehab until the infection subcided. We suggested to the company that they send me home with a visiting nurse. That, they didn’t want to pay for. Can someone help me with their logic?
Meanwhile, I feel as though we headed off a major attack by the germs with a pre-emptive course of heavy duty antibiotics. All we can do now is play the waiting game with the insurance company.
If anyone has any suggestions please pass them on.
I have learned to deal with the lymphedema in my lower extremities and no longer have problems with leg ulcers. However, I have been fighting chronic sinus and ear issues. Could my lymphedema be contributing to my body having a difficult time getting competely over this issue?
Dear Cynthia:
These issues are unrelated to your lower extremity lymphedema.
Kind regards
Methicillin Resistant Staph aureus is rampant due to the overuse of antibiotics(might consider colloidal silver orally). I have also seen fungal/yeast infections in patients with lymphedema. As a nurse I see a lot of untreated lymphedema. The terrible thing is the doctors are ignorant of the treatment for it and merely throw diuretics at it willy nilly. It is a shame to have people with extremities that have turned to “wood” or have scrotums burst due to this ignorance. Good luck in educating the AMA.
Lawrence
I was wondering if there is any research regarding the length antibiotics need to be administered before treatment? We have infectious disease and wound care doctors demanding treatment after 1 day.
Dear Steph:
As long as the patient is on antibiotics it is okay to start treatment with a prescription from the referring MD. It is advisable, however, to apply mild pressure in the affected area; deeper modalities, such as edema or fibrosis techniques, should not be applied. I would also suggest to apply a mild, well-padded compression bandage.
Dear Mr Zuther,
I very much appreciate your activities popularizing knowledge of lymphedema and especially in todays article its infectious complications. However, whenever we make anything public for the patients, we should be sure it has been based on objective findings. The terms cellulitis, erysipelas and lymphangitis are traditionally put in one sac although their etiology and pathomechanism are very different. First, any type of infection with a massive bacterial load is immediately evoking a reaction of the lymphatic system. Cellulitis (old anegdotal term used for inflammation of skin and subcutis) develops in parallel with lymphangitis of minor and collecting lymphatics. It is caused by patient’s own staphylococci and not streptococci. Second, lymphangitis is a part of tissue inflammation process, of inflamed tissues drained by the subsequently inflamed lymphatics. Lymphangitis is not a primary but a secondary process to tissue infection. Bacteria causing lymphangitis may belong to different strains, however, we know that the most common is Staphylococcus epidermidis. Third, most misunderstanding is connected with erysipelas. Erysipelas is a separate well defined entity caused primarily by Streptococcus of known serological type. It is an acute contagious disease requiring hospitalization and isolation. Infection can be transferred by patient himself to different parts of the body. Its consequences is usually lymphedema. Fortunately enough all the described conditions are relatively sensitive to antibiotics and are satisfactorily treated in the early stages. Taken together, cellulitis and lymphangitis should now called dermato-lymphangio-adenitis (DLA). This condition is the main and recurrent complication of obstructive lymphedema irrespective whether this last was caused surgery, infection or trauma. Erysipelas is not in this group as an etiologically different entity, although its consequence is usually lymphedema. The most effective prophylaxis against recurrency of DLA is long lasting penicillin in a dose 1200000 u every 3 weeks (longer intervals are complicated by recurrency) given for years. Longest follow-up is above 30 years. There is no resistance to penicillin or other antibioitcs as the chronic dose is extremely small. Please, read literature with my name in Pubmed and my monograph Lymph stasis, CRC Press, Boca Raton, FL from the late nineties. Regards.
Thank you for your valued comments, Professor Olszewski
I have had lymphedema for 21 years now do to having my lymphnodes removed in my groin area because of having melenoma. I have never had a problem with any of these infections but I do beleive it is because my doctor told me what to look for and to take good care of my skin on the effected area.
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Ended up in the hospital with Cellulitis in my bad leg. I now know that I must treat any insect bite/cut on the legs with a stronger ointment. I got Bactoban from my doctor and apply it at the first sign of an infected bite.
I have a similar situation to that of Joann Wilkins (see her post above, dated Nov. 3, 2010).
I have had lymphedema for about 20 years. In conjunction with my undergoing surgery for melanoma, my lymph nodes in the left axilla (armpit) were removed. Ten years later, a cat bit me on the left hand, the arm quickly became very infected, and, as they say, we were “off to the races.”
In the ensuing ten years I have been ambulanced to the E.R. 6 times with what I assume was acute cellulitis. My temp shot up to over 103, I could not “mentate” at all(couldn’t state my address, name the president, etc.).
They gave me i.v. antibiotics and fluids – and – voila! – I was back to normal, and was discharged, 24 yours later. Now, however, my wife has passed away and I live alone, and I fear what will happen the next time I have a situation like I described.
I, too, need to find out more about the use of broad-spectrum antibioitics.
I like your professional looking blog. It is very neat and tidy.
Hi i just found this site, can anyone help me out, I got lymhdema stright away ofter the removal of my breast and 37 nodes, a nurse took my blood presuer on that side and well, blow my arm up I when stright into surguery were they stapled everything and I had to have blood transfuses. They put a arm and sleave on and that was that I have to wear it all the time now other than night, I just got out of hospital now with cellulitis in my hand, a nurse come to put my drip on twice a day for the next 5 to 7 days, I keep asking DO I STill Wear my arm and hand But one says yes the other says no! what do I do? anyone know. sorry for the spelling etc thank you all.
Dear Trish:
I would like to refer you to two of my previous blog postings on the subject. Your questions will be answered there:
http://www.lymphedemablog.com/2010/10/22/lymphedema-risk-reduction-venipuncture-and-blood-pressure/
http://acols.com/lymphedematoday/?p=162
[...] prevents the build-up of additional fibrotic (scar) tissue and significantly lowers the risk of infections commonly associated with lymphedema. It is often necessary to adapt compression and exercise [...]
[...] in lymphedema can lead to secondary complications, such as hardening of the tissues over time, infections and increase in volume, especially in untreated or mistreated [...]
I have primary (congenital) lymphedema of my right leg, and had my first cellulitis infection at age 10. On average I get one infection per year, and have had about 15 infections. I have Kelfex on hand for the first presenting symptoms. About 3 weeks ago I had some stiffness and warmth present in my knee and took the keflex for a total of 8 days, as symptoms disappeared after day 4. However as soon as I stopped taking the Keflex, the infection quickly came back, so then I was put on Invaz (IV antibiotic) for 10 days, the last 5 of which were asymptomatic. Yesterday (first day without invanz or any antibiotics) the infection slowly started coming back again and now my range of motion is only 90 degrees. I went into the ER, but they said my WCC and inflammatory markers were all normal and referred me to my infectious disease specialist, who I’ve been working with on all other infections. MY QUESTION to you is…..what do you suspect is going on? Are the bacteria just not getting fully killed off? Could it be in the joint? If we suspect it’s in the joint, should aspiration be done (at risk of introducing bacteria into the joint if the infection is just in the soft tissues)? I wear a compression garment and I am an active ski and bike racer. Please give me any suggestions or input that you might have….I’d love to hear from you!
Thanks!
Dear Dustin: As you may already know, lymphedemateous tissue is prone to infections. It is also known that infections can be effectively controlled by decongesting the lymphedema and prevent fluid from re-accumulating. Another important factor is skin care – please refer to a previous blog post at http://www.lymphedemablog.com/2011/04/13/skin-and-nail-care-in-lymphedema-management/
If your leg is still swollen I would suggest seeking the services of a certified lymphedema therapist. Please click on the “Find a Therapist” button on the top of this page to locate a therapist in your area.
Thanks for the info. I did have decongestive therapy done about 12 years ago before I wore compression stalkings. My leg stays pretty much edema free now, as I wear the stalking every day. Are you suggesting I still have some lymphatic drainage massage performed, or can I do MLD on my own? Would you recommend being on a prophylactic antibiotic to help prevent these infections? The current infection is in my knee and it is becoming more swollen and painful. I am going to see the infectious disease specialist this afternoon. He’ll likely put me on antibiotics that will hopefully work this time. Should I also do MLD during this infection (there is no/little redness, it seems to be deep)? Should I use heat packs to help dilate the vessels?
If your leg is currently not swollen, there is no need to go for CDT treatments. However, it is always advisable to perform self-MLD in a way your were instructed by your therapist. It is your physician’s decision to recommend prophylactic antibiotics.