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Joachim Zuther, Lymphedema Specialist. Read more
Lohmann Rauscher
MediUSA

Tactile Medical

Infections Associated with Lymphedema

 

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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64 comments to Infections Associated with Lymphedema

  • avra bateson

    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.

  • Charlie

    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!

    • Joachim Zuther

      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

  • Robert Weiss

    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.

    • Joachim Zuther

      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.

    • Joachim Zuther

      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

  • Barbara LeBow

    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.

  • Cynthia Allen

    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?

  • Lawrence Loveless, RN, NMD, MHt,LMT

    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

  • Steph Romig MS, OTR CLT-LANA

    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.

    • Joachim Zuther

      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.

  • Olszewski Waldemar L

    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.

  • Joann Wilkins

    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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  • Kris Hawks

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  • Cremona22@hilroy.co.uk

    Fantastic blog! Great information for all of us suffering from lymphedema

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  • Khalilah Siegel

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  • Deb

    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.

  • George Ziskind

    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.

  • Mary Beth Gordon

    I like your professional looking blog. It is very neat and tidy.

  • trish

    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.

  • […] 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 […]

  • Dustin

    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!

    • Joachim Zuther

      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.

  • Dustin

    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?

  • Joachim Zuther

    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.

  • […] 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 […]

  • Liz

    Dr. Zuther, I have lower body (hip to toe) secondary LE of my right leg. LE and Lipedema in my buttocks and thigh. My LE started as a result of a puncture wound and infection, and came out as I was flying around the country on assignment. It’s gotten progressively worse over the years, and 2 hospitalizations for Cellulitis infections, never with an observable entry point.

    I’ve been through probably 12 courses of MLD/CDT over the 20 years I’ve had this condition, and the results have been highly mixed. The initial treatment brought me the most reduction. And over the years, with each successive MLD/CDT, I find the results to be minimal. I wear 2 stockings each day. One knee high, level 1, and a thigh high, level two. I wear one over the other. And I am still very swollen. Should I NOT be? Am I supposed to be normal sized? Not since my initial treatment was I ever close to that. Now, my right leg is close to double the size of the left leg, and I do daily Pilates Mat classes, and drink Apple Cider Vinegar, and keep my skin supple. I just don’t have any reduction whatsover and I am surprised to read here that I shouldn’t have swelling.

    • Joachim Zuther

      Dear Liz: Without knowing you personally, this is a question I am unable to answer conclusively. However, your right lower extremity should definitely not be double the size of your left leg. As you may know, it is difficult to reduce the tissue associated with lipedematous swelling, but there is no reason why your leg should still be that large, especially with you wearing compression garments. I would suggest to once more seek the services of a trained lymphedema therapist. You will be able to locate a therapist in your area by clicking on the “Find a Therapist” button on the top menu bar on this page.

  • Markie

    I am trying to find information on treatment for a blister like condition on my mothers LE’s. The fluid in the pockets appear clear. She is a diabetic with lymphedema and frequently occurring cellulitis. The compression wraps often open the blisters putting her at risk of infection. She is trying to manage or prevent the blisters, but she is not sure what causes them. Have you heard of this issue before?

    • Joachim Zuther

      Dear Markie: These blister like formations are known as lymphatic cysts. Their presence is indicative of high intralymphatic pressure. Your mothers lymphedema shold be evaluated and treated by a trained lymphedema therapist in order to minimize these cysts. You can locate a certified therapist in your area by clicking the “Find a Therapist” link on top of this page.

  • Stephanie

    Hi, I was diagnosed with cellulitis in my left breast a week ago today the swelling has gone down thanks to antibiotics but one spot is still sore I was told to take the antibiotics for ten days. What are the chances if another glare up after the antibiotics and does it always occur in the same place? I am so scared of a relapse because that is what I have heard. I go to doctor tomorrow so Hopi g for more answers.

    • Joachim Zuther

      While it is unlikely to have a flare up following oral antibiotics, it is possible. In that case antibiotica would be prescribed again.

  • I am so thank full for all the tips and advice my lymphedema start when I was in radiation treatment like the upper picture my arm and chest did look like that and I was sick all the time,after removed my Port-A-catch with sepsis in it and was growing on my skin with calcification now 3 Months later all the cellulitis is gone only swelling and stiffness in my arm that I try to bring down with wrapping!

  • Dee Grider

    Just getting over a group B strep infection in my right lymphedema arm( breast cancer-22 nodes removed). One doc said cellulitis the other thinks erysipelas. I spent a week in the hospital. I am now on 2 weeks of cefalexon 3/day at home. I have bilateral hip replacements. My reconstruction surgery scheduled in 4 weeks.

    I am under the care of a certified lymphedema therapist. My hand and arm have been swollen since Nov. We were just seeing some progress when the infection hit.

    My question is: what is the protocol for length of antibiotic treatment for a first attack?
    Thanks,
    Dee

  • Dee Grider

    Sorry that should say cefazolin IV antibiotics

  • Glenn

    Hello – I suffer with lymphedema to both legs. I have had cellulitis infections which seem to appear once every 5 years or so. I have painful arthritis in my left great toe. My podiatrist feels a toe joint transplant is the answer while my family medical internist believes this would be 90% risk and 10% success.

    The toe is so painful there are days I can barely walk. Should I rule out any toe joint replacement?

    Thank you.

    • Joachim Zuther

      I do not think that a joint replacement should be completely ruled out. As long as you know how to effectively manage your swelling, you should be fine following a possible replacement surgery. However, these issues need to be decided by your physicians.

  • Barbara

    I have lymphedema in my right leg and began therapy with a trained lymphedema therapist. She follows the Volder method. I was only two days into treatment when I developed cellulitis. I am now on a 10 day course of antibiotic and the therapist says we can resume treatment after that. I’ve had lymphedema in my leg for a few years and finally went for treatment due to lymph fluid leaking out of my calf. Is it possible that the wrapping of my leg contributed to me getting the cellulitis? I’ve never had a leg infection before and think it may not be a coincidence. I’m kind of nervous to continue treatment at this point. I really appreciate the information that I’ve read on this blog so far. Thanks for your thoughts and advice.

    • Joachim Zuther

      Dear Barbara: It is unlikely that treatment contributed to the onset of cellulitis. The leakage of lymphatic fluid more likely was the culprit. You should not be concerned about continuing treatment.

  • Betty Prazzo

    Currently being treated with bilateral unna boots for out of control lymphedema by vascular physician. Going into treatment, I had a blood blister which developed into an ulcer which sometimes bleeds and is very painful, especially because of the compression. Should I seek a wound specialist to treat the ulcer? This doc just applies medicated bandage.

  • Chip Chambliss

    Hell Mr. Zuther
    In October 2013 I had a pacemaker put in on my left side. Soon after (about 2 week)I started swelling on my left side starting in my arm. And the first 6 months or longer the Dr’s thought it was a blood clot. Now after 2 balloons and 2 stents in my left subcalvina, still swelling. My left eye is almost swelling shut. Fluid or swelling in my enter ear my equilibrium is out of control. One Dr thanks my thoracic duct is damage due to the pasemaker leads, that they had to remove to put the stents in and are still out. Another Dr thinks that the stents are blocking the thoracic duct(but I was swelling before the stents). Dr Chang in Chacigo said if this is so, surgery like this to repair the duct has never been done. I have gone through the PT, I get into the pool 2 to 3 times a week, I have a pump. Nothing helps! Do you have any thoughts on this.

    Thanks, Chip from Tennessee

    • Joachim Zuther

      Dear Chip:

      Without knowing you personally it is difficult to comment. However, due to the fact that the swelling started following the implant of the PM, it is likely that there is a correlation

  • Cinda from Missouri

    I have whole body lymphedema. I started taking Valium & stopped after 8 days due to it suppressing my immune system. I developed a staph infection on my right leg & Dr was pleased with how I was treating it. If it didn’t get to 1 cm by tomorrow, then she would prescribe an antibiotic. I discovered 2 more lesions on the left leg this am & have called my Dr for a script. My question is, when can I start wearing my 30-40 Mmgh compression garments again? I have a flexitouch for all limbs but haven’t used it in 2 days. I put on the light compression of 18-20 Solidea hose this am for about 30 minutes. They hurt so I took them off. I just don’t know when it’s OK to wear them because I don’t want the spread the infection. Any ideas would be greatly appreciated!

  • Abi

    Hi I have had Lymphodema in the right leg since 2005. I am now 40. I have never had an infection (cellulitis) but I worry if I ever get one. My leg is not severe or really large in size and it is of normal colour. It is soft, smooth and has no dry skin. Please advise if you are prone to infection by just having Lymphodema. Thanks

  • Nikki

    Hello. This article with all the questions and reply so has been very informative. I have lymphodema in my left arm after breast cancer treatment. Tonight my cat grabbed on to my arm to hold on from a fall. I now have a deep puncture and cut. I immediately washed with soap and hot water. I put triple antibiotics on it and covered with a Baid aid. Should I go to the doctor in the morning and just start antibiotics to prevent infection?? Should I use my pump machine to help reduce any swelling in the morning???
    Thanks for helping.

    • Joachim Zuther

      You handled the situation well. If you realize any signs of infection, you should consult with your physician

  • Suzanne Grabber

    Hello. I have Fibromyalgia,along with several related issues. Have had Fibro for over 30 yrs. About 10 yrs ago was prescribed Lyrica. After taking it for a day or two my legs began to swell. I called Dr. She said it was a side effect and would go away. I had an appt in a few more days, meanwhile my legs just kept getting bigger. At appt. Dr not concerned, nurse however told me in no uncertain terms to go to the emergency room and stop taking the Lyrica. Turns out I ended up with Lymphedema in both legs. Had to bandage, wear compression socks, manual drainage…I even had fluid leaking from my pores for a while. Once had cellulitis and was in hospital. Anyways, after several years wearing compression socks faithfully, I haven’t had much if any swelling. I thought maybe my Lymphedema had gone away. Can it go away? I’m thinking no as I hit my leg on a corner of a car door. Small cut, big bruise now turning red and itchy and feeling slightly warm. All this stuff years ago has come rushing back to my head, but still no real swelling. I have dr. Appt next week. Any insight or advice?

    • Joachim Zuther

      Suzanne: The swelling in your legs may have been caused by the medication. If indeed the swelling was/is lymphedema, there will be always a risk of re-accumulation of fluid. The other scenario would be that you have managed your lymphedema well, and it went into a stage of latency (no visible swelling) – however, there could still be microscopic swelling in your tissues, which would make it susceptible to infections.