Gastrointestinal: Symmetric lymphangitis of lower limbs originating from a perianal abscess

Abstract

A 45-year-old male patient presented with perianal pain that occurred during defecation, fever of 38.2°C and malodorous perianal discharge. He also complained of diffuse numbness and mild pain of the legs bilaterally. On examination, a perianal tender, warm, fluctuating mass was found. Palpation and digital exam of the anal canal were extremely painful and poorly tolerated. A diagnosis of a perianal abscess was hence made. On complete physical examination linear, raised, red striae were observed on the medial side of both lower limbs, extended symmetrically from the perineum to the medial malleolus of each leg (Figures 1a–c). These striae were painful on palpation. Also mild ankle oedema was present bilaterally (Figure 2). These findings were consistent with the diagnosis of acute, superficial symmetric lymphangitis of the lower limbs. Lymphangitis is an inflammation of the lymphatic channels that may occur as a result of infection at a site distal to the channel; a bacterium was cultured, a Streptococcus pyogenes, confirming the diagnosis of an infective congestion. Bacterial lymphadenitis and lymphangitis may either follow a direct infection of a lymph node, or due to spread of the bacteria along the lymphatic channels from a distant source along the tributary of lymphatic vessels. Severe lymphangitis of deep tissues needs to be differentiated from necrotizing fascitis. Treatment of acute superficial lymphangitis consists of removal of the infected tissue, if present, and antibiotics. Systemic or local antifungal agents are required for fungal infections. Anticoagulants may be advocated for patients at high risk of thrombosis. Cortisone is useful during the acute phase, while NSAIDs should be prescribed as analgesia. In our patient lymphangitis originated from perianal sepsis due to a perianal abscess, and spread via a retrograde pattern down both legs bilaterally. The patient was not immunosuppressed. We performed colonoscopy which was negative for proctitis or Crohn's disease. Surgical incision of the abscess with drainage, curettage with debridement was performed. Oral antibiotic with amoxicillin-clavulanic acid 875 mg/ 125 mg b.i.d. for 3 days was provided with complete resolution of signs and symptoms at 1-week follow-up.