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Background: Thoracoscopy is the “gold standard” diagnostic modality for investigation of suspected pleural malignancy. It is postulated that meticulous assessment of the pleural cavity may be adequate to indicate malignancy through the macroscopic findings of nodules, pleural thickening, and lymphangitis. We attempted to critically assess this practice, by precisely defining objective macroscopic criteria which might differentiate benign from malignant pleural diseases according to intrapleural pattern and anatomical location, and thereby to explore the predilection of abnormalities to specific sites on pleural surfaces. Methods: A structured review of recorded video footage from medical thoracoscopy procedures in 96 patients was conducted by 2 independent assessors. Abnormalities were scored on agreed, objective criteria for the presence of nodules, lymphangitis and inflammation on each of the costoparietal, visceral and diaphragmatic surfaces. The costoparietal pleura was divided into 6 levels (apical, middle, and inferior surfaces of the lateral and posterior parietal pleura). The anterior surface of the costoparietal pleura was excluded from analysis after interim review as this surface was rarely seen. Results: In the benign group, inflammation was the predominant finding in 65% (n = 33; costoparietal), 44% (n = 21; visceral), and 42% (n = 15; diaphragmatic). Nodules were detected in 24% (n = 12; costoparietal), 8% (n = 4; visceral), and 8% (n = 3; diaphragmatic). The most affected surfaces with inflammation were the middle lateral (60%) and the inferior lateral (57.8%) parts of the costoparietal pleura. In the malignant group, nodules were the predominant finding according to surface in 73% (n = 33; costoparietal), 32% (n = 13; visceral) and 48% (n = 17; diaphragmatic). Inflammation was detected in 44% (n = 20; costoparietal), 25% (n = 10; visceral), and 29% (n = 10; diaphragmatic). The most affected surfaces with nodules were the middle lateral (67.4%) and inferior lateral (66.7%) costoparietal pleural surfaces. Conclusion: This is the first detailed, anatomical description of abnormalities in the pleural space during thoracoscopy. While nodules were the predominant pattern in malignant pleural effusion, they were detected in 24% of benign diagnoses. Detection of nodules in >1 area of the costoparietal pleura was in favor of a malignant diagnosis. Inflammation was the predominant pattern in benign pleural effusion. Our results suggest that macroscopic nodules in malignant diagnoses have a predilection for the middle and inferior surfaces of the lateral costoparietal pleura.

Objectives Little is known regarding the differences in microbiology associated with cellulitis or abscess with or without lymphangitic streaking. The objective of our study is to assess whether there are differences in the pathogens identified from wound cultures of patients with paronychia with and without associated lymphangitis. Methods Retrospective cross-sectional study at a tertiary pediatric emergency department over 25 years. We opted to assess patients with paronychia of the finger, assuming that these cases will have a greater variety of causative pathogens compared to other cases of cellulitis and soft tissue abscess that are associated with nail biting. Case identification was conducted using a computerized text-screening search that was refined by manual chart review. We included patients from 1 month to 20 years of age who underwent an incision and drainage (I&D) of a paronychia and had a culture obtained. The presence or absence of lymphangitis was determined from the clinical narrative in the medical record. We excluded patients treated with antibiotics prior to I&D as well as immune-compromised patients. We used descriptive statistics for prevalence and χ2 tests for categorical variables. Results Two hundred sixty-six patients met inclusion criteria. The median age was 9.7 years [IQR 4.7, 15.4] and 45.1% were female. Twenty-two patients (8.3%) had lymphangitic streaking associated with their paronychia. Patients with lymphangitis streaking were similar to those without lymphangitis in terms of age and sex (p = 0.52 and p = 0.82, respectively). Overall, the predominant bacteria was MSSA (40%) followed by MRSA (26%). No significant differences were found between the pathogens in the 22 patients with associated lymphangitis compared to the 244 patients without. Conclusion Staphylococcus aureus represent the majority of pathogens in paronychia, although streptococcal species and gram-negative bacteria were also common. Among patients with paronychia of the finger, there seems to be no association between pathogen type and presence of lymphangitic streaking.

The clinical manifestations of a recluse spider bite range from local erythema to necrotic skin reactions; bites rarely lead to a systemic disease known as viscerocutaneous loxoscelism. A 29-y-old female patient was admitted to the emergency department with a wound, swelling, and pain on her left leg and a rash on her whole body as a result of a spider bite. On physical examination, a round, hard, black, irregularly shaped necrotic area was found in the bite zone on the lower posterior part of the left thigh, as were lesions in the form of erythematous papules around the area. There was a color change around the lesion, extending from posterior to medial of the thigh, and a papule on a diffuse erythematous surface on the trunk and arms. At follow-up, the necrotic area had become more apparent. After approximately 1 mo, the necrotic area was surgically debrided and a flap was formed on the necrotic tissue area. In this article, a case that was thought to be caused by a Loxosceles spider bite and which started with erythema, progressed to lymphangitis, cellulitis, and severe necrosis, and was surgically debrided, was evaluated in light of the clinical findings and previously reported cases of verified loxoscelism. In patients with a history suggestive of a bite and with these clinical findings, the diagnosis of a bite by Loxosceles spp. should be carefully considered based on clinical and epidemiologic findings.

Erysipelas, a variant of cellulitis, is a superficial dermal bacterial infection. This superficial cutaneous infection may cause lymphangitis with resultant lymphedema in poorly treated cases. Reports of erysipelas preceding lymphedema are rare, rather many have reported the occurrence of erysipelas in patients with subclinical or overt lymphedema. Two case reports of erysipelas preceding lymphedema after appropriate parenteral antibiotics therapy and limb elevation are here presented. Following diagnosis, admission, and commencement of therapy, the second patient (Case 2) discontinued hospital treatment halfway for native treatment and returned after about 3 weeks. All patients recovered successfully but later presented with lymphedema after 8 weeks and 6 weeks, respectively. Both patients made a sustained functional recovery of their limbs with conservative management including elastic compression stocking and limb elevation. Erysipelas infection preceding lymphedema may develop when it occurs, prompt and appropriate treatment modalities for erysipelas infection may forestall the development of lymphedema.

As dermo-hipodermites bacterianas agudas não necrotizantes são processos infeciosos que incluem a erisipela e a celulite infeciosa, e são geralmente causadas por estreptococos β–hemolíticos do grupo A. Em mais de 80% dos casos situam-se nos membros inferiores e são fatores predisponentes a existência de solução de continuidade na pele, o linfedema crónico e a obesidade. O seu diagnóstico é essencialmente clínico e o quadro típico baseia-se na presença de placa inflamatória associada a febre, linfangite, adenopatia e leucocitose. Os exames bacteriológicos têm baixa sensibilidade ou positividade tardia. Nos casos atípicos é importante o diagnóstico diferencial com a fasceíte necrotizante e a trombose venosa profunda. A flucloxacilina ou a cefradina são os fármacos de primeira linha. A recidiva constitui a complicação mais frequente, sendo fundamental o correto tratamento dos fatores de risco.

Background Immunoglobulin G4-related disease (IgG4-RD) is a multi-organ disorder predominantly occurring in middle-aged to elderly male patients characterized by multi-organ fibrosis, specific pathological findings of storiform fibrosis with IgG4-positive plasma cell infiltration, and elevated serum IgG4 level. We herein report a rare presentation of IgG4-RD forming an isolated mass in the middle mediastinum mimicking a mediastinal tumor and discuss the clinical significance of mediastinal IgG4-RD. Case presentation An 82-year-old male patient without any symptom was referred due to left middle mediastinal mass (3.8 × 2.4 cm). Because of suspected lymphoma, Castleman’s disease, and lymphangitis due to tuberculosis, we performed a thoracoscopic resection for diagnosis and treatment. The mass was yellowish white with well-encapsulated, and storiform fibrosis with plasma cell infiltration, and obliterative phlebitis were observed microscopically. Additional immunohistochemical stain revealed IgG4-RD. Other radiological findings and serological results did not show evidence of other organs being affected from IgG4-RD nor autoimmune diseases. He is now followed at outpatient clinic without additional treatment for over a year, and an enhanced computed tomography does not show any recurrence. Conclusion It was a rare presentation of IgG4-RD forming isolated middle mediastinal mass, which suggests that we might suspect IgG4-RD for undetermined mediastinal mass in case of middle to elderly male patient.

Patients with cancer are at higher risk of more severe COVID-19 infection and have more associated complications. The position paper describes the management of cancer patients, especially those receiving anticancer treatment, during the COVID-19 pandemic. Dyspnea is a common emergency presentation in patients with cancer with a wide range of differential diagnoses, including pulmonary embolism, pleural disease, lymphangitis, and infection, of which SARS-CoV-2 is now a pathogen to be considered. Screening interviews to determine whether patients may be infected with COVID-19 are imperative to prevent the spread of infection, especially within healthcare facilities. Cancer patients testing positive with no or minimal symptoms may be monitored from home. Telemedicine is an option to aid in following patients without potential exposure. Management of complications of systemic anticancer treatment, such as febrile neutropenia (FN), is of particular importance during the COVID-19 pandemic where clinicians aim to minimize patients’ risk of infection and need for hospital visits. Outpatient management of patients with low-risk FN is a safe and effective strategy. Although the MASCC score has not been validated in patients with suspected or confirmed SARS-CoV-2, it has nevertheless performed well in patients with a range of infective illnesses and, accordingly, it is reasonable to expect efficacy in the clinical setting of COVID-19. Risk stratification of patients presenting with FN is a vital tenet of the evolving sepsis and pandemic strategy, necessitating access to locally formulated services based on MASCC and other national and international guidelines. Innovative oncology services will need to utilize telemedicine, hospital at home, and ambulatory care services approaches not only to limit the number of hospital visits but also to anticipate the complications of the anticancer treatments.

Background This study analyzed and described factors related to necrotizing or non-necrotizing soft tissue infections (SSTIs) in a hospitalized patient population in Northeastern South America. Materials and methods This retrospective study included patients hospitalized with SSTIs between January 2011 and December 2016. The main factors related to necrotizing SSTIs (NSTIs) or non-necrotizing SSTIs were analyzed together or separately. Results Of 344 SSTI patients (161 [46.8%] non-necrotizing, 183 [53.2%] necrotizing), NSTI patients had a higher incidence of heart disease (P = 0.0081) and peripheral arterial disease (PAD; p, Highlights • Patients with necrotizing infections and poor glycemic control have higher risks for amputation. • Diabetes as a risk factor most associated with soft tissue infections. • Peripheral arterial disease is the main risk factor for amputation and death. • Soft tissue infections with necrosis evolve with more complications and risk of amputation and death.

Introducción: el síndrome linfocutáneo es una forma clínica muy característica de linfangitis, que se presenta con nódulos inflamatorios subcutáneos que siguen un trayecto. Se han descrito múltiples patologías infecciosas que podrían tener esta presentación clínica y su enfoque diagnóstico es clave para un tratamiento acertado. Métodos: se realizó una búsqueda en PubMed MEDLINE y, posteriormente, una revi­sión narrativa describiendo las diferentes etiologías infecciosas del síndrome linfocutáneo. Resultados: el síndrome linfocutáneo puede tener múltiples causas, dentro de las cuales se encuentran infecciones micóticas, bacterianas, por micobacterias típicas o atípicas, y parásitos, siendo Sporothrix schenckii, Nocardia bra­siliensis, Mycobacterium marinum y Leishmania sp. los agentes más frecuentemente asociados. Para determinar su etiología, es necesario considerar aspectos en la anamnesis (procedencia, ocupación, tiempo de evolución, an­tecedente de trauma), semiología de las lesiones, sintomatología asociada y, en muchos casos, confirmación diag­nóstica con biopsias de piel, cultivo o tinción de Gram, u otros. Su tratamiento debe ser dirigido y, generalmente, debido al compromiso de trayectos linfáticos, se extiende por más tiempo respecto a las infecciones localizadas. Conclusiones: cuando nos enfrentamos a un paciente con hallazgos sugestivos de síndrome linfocutáneo, de­bemos considerar múltiples etiologías infecciosas. Con el fin de hacer más sencillo el enfoque diagnóstico, propo­nemos clasificar los agentes causales en 4 grandes grupos: infecciones micóticas, bacterianas, por micobacterias y parasitarias.

Nocardia takedensis was first isolated in 2005, from soil in Japan. We report here two cases of lymphangitis in France (2012–2017) caused by N. takedensis both occurring after skin injury while gardening, which enabled its inoculation. The two patients were immunocompromised and successfully treated by an antimicrobial agent active on the isolated strain, trimethoprim-sulfamethoxazole and amoxicillin-clavulanic acid for patient one and patient two, respectively. Our study along with previous ones supports the idea of a newly recognized cutaneous opportunistic pathogen and reinforces the recommendation of using gloves during soil exposure for immunocompromised patients. Lastly, according to data found in the literature, we would recommend trimethoprim-sulfamethoxazole as an efficient empirical antibiotic therapy in case of cutaneous infection caused by N. takedensis.

Introduction: Breast cancer is the most common female cancer in the world. The prognosis depends on whether metastasis is present or not. The objective of this study was to provide an overview of the CT scan aspects identified during the evaluation of breast cancer extension in the Radiology department of the Teaching University Hospital of Hubert Koutoukou Maga (CNHU-HKM) in Cotonou in Benin.Materials and Methods: It was a descriptive study with retrospective collection, conducted from January 1, 2018 to January 31, 2019 (13 months), in the Radiology department of CNHU-HKM. It focused on patients referred for a chest-abdominal-pelvic computed tomography (PET) scan, as part of an extension assessment for breast cancer. Results: During the period of the study, 40 chest-abdominal-pelvic CT scans were compiled, of which 38 (95%) were women and 02 men (5%), and among which 23 were metastatic, accountings for a prevalence of 57.5%. The average age was 51.22 ± 16.33 with extremes of 30 and 83 years old. Among our patients, 32 (80%) had undergone a CT scan for an initial diagnostic of extension assessment, and 08 (20%) for the therapeutic response assessment. According to the TNM classification, T4 tumors accounted for 27.5% (11 cases). Lymph node involvement was found in 18 cases (43.90%), accounting for 12 (30%) of N1 and 6 (15%) of N3. The most commonly found metastatic sites were the lung in 25% followed by the pleura and the liver with equal percentages (10%). The metastases CT scan aspect was typically a carcinomatous lymphangitis appearance; fluid pleural effusions; hypodenses hypovascular nodules hepatics; osteolytic or mixed bone damage and peritoneum, especially fluid effusion associated with peritoneal nodules.Conclusion: The frequency of breast cancer metastases is high in Benin. The most commonly found metastatic sites on scanner in descending order are the lungs, liver and bones.

Highlights • We showed a different presentation of Castleman disease. • Our service role out parasitic, mycotic, oncologic causes. • Firstly we treat with antibiotics because the patient did not show any clinical improvement. We opted for a surgical treatment. • All the decisions were discussed with the patient. • The surgical treatment for soft tissue disease contributes to returning the patient's social and familial activities., Introduction Castleman disease (CD) is a lymphoproliferative disorder with lymph node hypertrophy. In the unicentric form (UCD), it affects one lymph node or chain of lymph nodes. In the multicentric form (DCM), there is hypertrophy of several lymph node chains with the formation of tumor masses, causing compressive symptoms. This case report showed a case of CD in a different location(inguinal region) associated to a multiple skin lesions. Presentation of the case We reported a UCD in a 43-year-old female patient with no previous comorbidities. Since January 2016, this patient developed erysipelas lesions of the left leg (LL) from the thigh root to the foot. Concomitantly, a tumor mass appeared in the inguinal region. In 2019 we performed a biopsy that revealed changes characteristic of CD. Due to extremely poor trophic conditions, the skin area with erysipelas was resected, and the raw surface was grafted. Discussion As an inference, the erysipelas may have been responsible for the subsequent lymphangitis, lymphedema and lymph node hypertrophy. Conclusion Resection of the diseased skin and lymph node excision constitute the treatment of UCD and result in improvement of the clinical picture. Nevertheless, further study of the inflammatory reaction and of markers such as interleukin-6 and the presence of skin disorders in DC is needed.

Introduction Syphilis is one of the most common diseases that start with genital ulcers. Aside from the initial, classic ulcerative lesion of syphilis, called hard chancre, atypical presentations are common, with erosions, erythema, edema, balanitis, and other dermatological conditions. Associated with initial genital lesions, the presence of inguinal adenopathies is frequent, and the presence of hardened and painless lymphangitis on the dorsum of the penis is rare. Objectives To describe atypical penile manifestations in patients with early syphilis. Methods The present study reports patients who developed cord-like lesions on the penis. Results The study included 25 patients with cord-like lesions on the penis; in 19 of those, the diagnosis of syphilis was confirmed. Study limitations Small number of patients included. Conclusions In view of the findings of the present investigation, it is important to emphasize that all patients who present with cord-like lesions on the penis must undergo a rapid test for syphilis, VDRL, serologies for HIV and, viral hepatitis B and C and, whenever possible, histopathological and Doppler exams.

Lymphomatous involvement of the lungs manifests in an infinite number of ways. Often there is a considerable overlap of the patterns of manifestations which comes as a diagnostic challenge to the radiologist. We retrospectively reviewed the pulmonary manifestations of biopsy proven cases of primary or secondary non-Hodgkin's lymphoma or Hodgkin's lymphoma. The patterns of lung involvement were then classified into broad categories which included large masses, mass like consolidation, nodules with or without cavitation, ground glass and lymphangitis/ perilymphatic pattern. This article illustrates the spectrum of CT manifestations of lung involvement in non-Hodgkin's lymphoma as well as Hodgkin's lymphoma.

Rickettsia sibirica mongolitimonae is considered a rare pathogen that can cause different clinical presentations. Approximately, one-third of the patients with this infection experience lymphangitis from the inoculation eschar to the draining lymph nodes, and, in that case, the infection is named “lymphangitis-associated rickettsiosis” (LAR). There are several reports of infections by this Rickettsia but none of LAR in children. We report a case of LAR in a Spanish child, which confirms the distribution of this agent in our country, and his implication in pediatric population.

We describe the case of a 45-year-old woman with an unusual presentation of metastatic ovarian cancer. The patient presented to the oncological clinic with a three-week history of skin rash on the right breast. She underwent a chest and abdomen CT scan, which showed skin thickening of the right breast, right pleural effusion and bilateral cystic ovarian masses. Biopsy of a left ovarian lesion by diagnostic laparoscopy revealed the presence of ovarian serous carcinoma. Biopsy of the breast skin lesion revealed the presence of carcinomatous lymphangitis and immunohistochemistry documented the ovarian origin.

Background Most cases of lymphoedema are secondary to other causes, while cases of primary lymphoedema, in particular that of congenital origin, are uncommon. Limited genetic disorders are so far known to be associated with lymphatic malformation including mutations in RASA1. This clinical case highlights the possible complications of RASA1-associated lymphatic malformation in a female suffering from recurrent life-threatening septic lymphangitis. Case summary A 23-year-old female patient presented with congenital lymphoedema of the lower right extremity. At the age of eight, she first suffered from an episode of lymphangitis. Thereafter, she developed recurrent episodes of lymphangitis predominately occurring during menstruation and culminating into severe and life-threatening septicaemias. Due to the menstrual association, endometriosis was suspected but could not be confirmed. Furthermore, angiography could not detect any sign of arteriovenous fistula. Single-Photon-Emission-Computed-Tomography confirmed absent major lymphatics of the right leg with severely impaired and prolonged dermal lymphatic backflow. Genetic testing identified a disease-causing variant in the RASA1 gene. Discussion To our knowledge, this is the first case of recurrent septic lymphangitis with close relation to menstruation in a female with RASA1-associated lymphatic malformation. Due to the possible de novo or somatic origin of a pathogenic variant, a genetic disease should be considered in spite of an unremarkable family history or a localized lymphoedema. Although there is no curative therapy available yet, the knowledge of the underlying genetic defect is important for interdisciplinary patient care and might be crucial for individual molecular therapies in the future.

Cutaneous metastases are rare. They usually present as nodules or tumors. Diagnosis is based on histopathological examination and prognosis is unfavorable. This report describes the case of a female patient, 72 years old, with surgically treated gastric antrum adenocarcinoma. Pathology showed poorly differentiated adenocarcinoma with signet ring cells. It evolved with bone involvement, lymph node enlargement in the inguinal region, and skin infiltration in the lower limbs, abdomen, and root of the upper limbs. Skin biopsy demonstrated signet ring carcinoma embolizing the dermal and hypodermic vessels and invasion of adipose tissue, confirming carcinomatous lymphangitis. Carcinomatous lymphangitis is the cutaneous and subcutaneous lymphatic invasion by tumor cells. Cutaneous metastasis is relatively uncommon and presents mainly as cutaneous or subcutaneous nodules, and more rarely as inflammatory lesions. The present case reports carcinomatous lymphangitis associated with gastric cancer.

Background Herpetic whitlow is a viral infection caused by the herpes simplex virus (HSV) types 1 or 2, and occurs in the pediatric population primarily on the fingers and toes due to autoinoculation from oral secretions. Because of this cited prevalence, other locations of herpetic whitlow may go unrecognized. Case presentation We present an atypical presentation of palmar herpetic whitlow with delayed recognition and associated viral lymphangitis. The patient presented as a transfer from an outside hospital with a progressive, three-day history of a suspected left hand abscess preceded by left hand pain and itching. She was initially evaluated by Orthopedic Surgery, who described an erythematous, edematous, tender, left palmar abscess with associated erythematous streaking up her forearm. The lesion was surgically managed with an incision and drainage. Wound cultures were obtained during which “minimal drainage” was noted. After admission to the General Pediatrics Hospital service, the lesion was noted to appear vesicular and subsequently obtained PCR samples were positive for HSV type 1, confirming her diagnosis of herpetic whitlow. Although she remained afebrile with negative wound cultures throughout her hospitalization, a secondary bacterial infection could not be conclusively excluded due to the accompanying lymphangitis. Thus, she was discharged with oral antibiotics and anticipatory guidance of potential recurrence of palmar lesions. Conclusions Herpetic whitlow should be included in the differential diagnosis of palmar lesions that appear vesicular or abscess-like to ensure appropriate treatment. Additionally, these palmar lesions may present with associated lymphangitis without evidence of bacterial infection.

A healthy 2-year-old boy developed a sudden-onset painful rash while on a walk outdoors in Texas. The caretaker noted that the walk was uneventful, and the course taken was a paved neighbourhood sidewalk travelled many times without incident. During the walk, the toddler picked up rocks, leaves and various other objects on the ground. On exam, edematous plaques with lymphangitis were noted on the left arm. He was inconsolably …

Introduction: nodular lymphangitis (NL) may be a manifestation of various infectious and non-infectious conditions, characterised by subcutaneous inflammatory nodules that extend from the site of the primary focus to the regional lymph nodes. NL usually constitutes a challenge in primary health care, and histopathological and microbiological evaluations are necessary to establish the definitive diagnosis. Methods: We report a classic case of NL that developed in the upper limb of a middle-aged man after trauma on the right thumb. The objective: was to emphasise some aspects of the differential diagnosis in a patient with NL and to reduce the rate of misdiagnosis in the scenery of initial medical attention. Results: the clinical manifestations were non-specific, but the microbiological study revealed typical characteristics of sporotrichosis. The treatment with itraconazole (200 mg daily) for six months was successful. Conclusion: NL constitutes a challenging condition and the early diagnosis depends on a high index of suspicion. Case reports may reduce late diagnoses with unfavourable results.

The tumor, node, metastasis (TNM) staging system approved by International Association for the Study of Lung Cancer (IASLC) and the American Joint Committee on Cancer (AJCC) to stage lung cancer was recently revised. The latest revision is the 8th edition published in January, 2017. This new edition made some important changes to the previous edition, including modification of the T classification based on 1 cm increment, downstage of T descriptor including endobronchial tumor disregarding its distance from carina (T2), merging total and partial atelectasis/pneumonitis into the same T category (T2), upstage diaphragmatic invasion to T4, new classification concept of adenocarcinoma in situ and minimally invasive adenocarcinoma for pure and part-solid ground-glass nodules, and further division of extrathoracic metastasis into M1b and M1c based on the number and sites of extrathoracic metastases. Consensus is reached for debating situations not covered in the previous edition of staging system, such as the classification of pancoast tumor based on its invasion depth and staging tumors that extend directly across the fissure as T2a. Classification of multiple sites of pulmonary involvement, including multiple primary lung cancer, separate lung cancer nodules, multiple ground-glass or lepidic lesions, and consolidation, is also discussed. Even though the 8th edition of the TNM lung staging system provides us with more precise classification based on prognostic analysis of each TNM descriptors, there are still some potential limitations and clinical situations that have not yet been clarified in terms of clinical staging by imaging. It is important for radiologists to understand the major changes introduced in the 8th edition of TNM staging and to recognize the potential pitfalls and limitations of imaging interpretation to precisely classify the clinical stage of lung cancer.

Pulmonary lymphangitis carcinomatosis (PLC) is a life-threating complication in patients suffering from malignancies. Misleading and nonspecific symptoms often result in a delayed diagnosis. This review was aimed at evaluating epidemiology, clinical manifestations, and survival of patients with PLC reported in the literature. According to our knowledge, this study is the first such extensive analysis of PLC. We searched for the literature in the PubMed database for articles published from 1970 to 2018 using keywords: lung, pulmonary, lymphangitic, carcinoma, carcinomatosis. Pulmonary lymphangitis carcinomatosis rarely occurs, thus all data were extracted from case reports and case series consisted of a method for identifying individual-level patient data. In the final analysis, 108 articles (139 individual patient cases) were included. The mean age of PLC occurrence is 49.21 years. There is no difference in the prevalence between men and women. The most common underlying primary tumors coexisting with PLC are breast (17.3%), lung (10.8%), and gastric cancers (10.8%). Dyspnea and dry cough were the most common symptoms occurring in 59.0% and 33.8% of patients, respectively. In half the patients, PLC developed in fewer than ten months after first diagnosis of cancer. Pulmonary lymphangitis carcinomatosis diagnosis is associated with a poor prognosis: approximately half of patients die within two months of their first respiratory symptoms and three weeks from admission to hospital. Regarding survival time, we observed better results achieved in patients described between 2000 and 2018 compared to 1970 through 1999. In the presence of progressive dyspnea, cough, and lesions comparable to interstitial lung disease, diagnosis of PLC should be considered. Pulmonary lymphangitis carcinomatosis can be the first manifestation of primary occult neoplasm and may occur at any age. Adenocarcinoma, especially primary lung, breast, and gastric cancers is the most common cancer coexisting with PLC.

BACKGROUND A tropical ulcer is a bacterial necrotizing disease of the skin, with an acute or chronic clinical course, caused by anaerobic bacteria, notably Fusobacteria spp. OBJECTIVES We present six Italian tourists who acquired tropical ulcers in tropical and subtropical countries. MATERIALS & METHODS Four males and two females acquired a skin ulcer during trips to Brazil, Malaysia, Fiji Islands, Zambia, Tanzania and India. In all patients, medical history, physical and dermatological examination, laboratory tests, bacteriological examinations and biopsy were carried out. RESULTS All patients were in good general health. All patients stated that the ulcer was caused by a trauma. No fever was reported. Neither lymphangitis nor lymphadenopathy were detected. The ulcer was located on a forearm in one patient, on a leg in two and on an ankle in three patients. All ulcers were malodorous and painful. Laboratory tests revealed mild leucocytosis and a mild increase in erythrocyte sedimentation rate and C-reactive protein. Results of bacteriological examinations revealed the presence of Fusobacterium spp. in five patients. Other bacteria were identified in all patients. Histopathological examination showed: necrosis of the epidermis and dermis; vascular dilatation; oedema in the dermis; massive infiltration with neutrophils, lymphocytes and histiocytes; and fragmented collagen bundles. No signs of vasculitis were observed. All patients were successfully treated with oral metronidazole (1 g/day for two weeks) and, according to antibiograms, with different systemic antibiotics. CONCLUSION To our knowledge, these are the first cases of tropical ulcers reported in Western tourists.

International audience; No abstract available

Background Thoracoscopy is the ‘gold standard’ diagnostic modality for investigation of suspected pleural malignancy.1 It is postulated that meticulous assessment of the pleural cavity may be adequate to diagnose malignancy through finding of nodules, pleural thickening and lymphangitis.2 Given the increased uptake of local anaesthetic thoracoscopy (LAT) recently, we attempted to define precise, objective criteria to differentiate benign from malignant pleural diseases according to the pattern, anatomical site and exploring predilection of abnormalities to specific sites on the pleural surfaces. Methods A structured review of recorded video footage from LAT procedures in 96 patients was conducted by 2 independent assessors. Abnormalities were scored according to the presence or absence of nodules, lymphangitis, inflammation on each of the parietal, visceral and diaphragmatic surfaces, respectively. The parietal pleura was divided into 6 levels (apical, middle, and inferior of the lateral surface and apical, middle, and inferior of the posterior surface). The anterior surface of the parietal pleura was excluded due to difficulty of assessment. Results In the benign group, inflammation was the predominant finding in 65%(n=33; parietal), 44%(n=21; visceral) and 42%(n=15; diaphragmatic). Nodules were detected in 24%(n=12; parietal), 8% (n=4; visceral) and 8%(n=3; diaphragmatic). The most affected surfaces with inflammation were the middle lateral (60%) and the inferior lateral (57.8%) parts of the parietal pleura. In the malignant group, nodules were the predominant finding in 73%(n=33; parietal), 32%(n=13; visceral) and 48%(n=17; diaphragmatic). Inflammation was detected in 44%(n=20; parietal), 25%(n=10; visceral) and 29%(n=10; diaphragmatic). The most affected surfaces with nodules were the middle lateral (67.4%) and the inferior lateral (66.7%) parts of the parietal pleura. Conclusion This study suggests that macroscopic assessment at LAT can differentiate between benign and malignant pleural disease, with the predominance of inflammation and nodules, respectively. In addition, pleural abnormalities appear to have an anatomical predilection, emphasising the importance of inspection and sampling of these areas. The finding that nodules were seen in approximately 1 in 4 benign patients on the parietal pleura is of interest and warrants further exploration in a larger cohort. References Rahman NM. Thorax 2010; 65: ii54–ii60. Boutin C. Endoscopy 1980; 12(04): 155–160.

Background It has been postulated that when the intrapleural tumour burden is high, the resultant obliteration of normal mesothelial cell surface of the pleura results in reduction in pleurodesis success rate.1 This effect has been suggested in the context of worse pleurodesis outcomes in malignant pleural effusion (MPE) secondary to lung cancer or mesothelioma, with more favourable outcomes seen in breast and ovarian cancer.2 This study therefore aimed to assess the hypothesis that tumour burden is associated with higher pleurodesis failure, and that tumour type can affect pleurodesis outcomes. Methods A structured, retrospective review of recorded video footage of local anaesthetic thoracoscopy (LAT) procedures of 45 patients with proven MPE was conducted by 2 independent assessors blinded to the patient medical records. Abnormalities were assessed according to the presence or absence of; nodules, lymphangitis, inflammation, and adhesions on each of the parietal, visceral and diaphragmatic surfaces. A macroscopic score was developed by adding the number of abnormalities in each pleural surface to produce a total score for tumour burden. Two separate assessors correlated the findings with tumour type and pleurodesis outcome from the patient`s clinical records. Results In both mesothelioma (n=21) and non-mesothelioma (n=24), there were no significant differences between the tumour burden score and the outcome of pleurodesis (p=0.188 and 0.173 respectively). The rate of pleurodesis success was higher in the non-mesothelioma group (n=16; 66.7%) compared to the mesothelioma group (n= 9; 42.9%) with no significant difference between both groups (p=0.11) Conclusion In this study, we found no relationship between tumor burden and pleurodesis outcome. While the blinded and detailed analysis of LAT video footage is an important strength of this study, it has significant limitations, namely small numbers and retrospective methodology. Nonetheless it adds important insights that would go against our assumed understanding of this relationship between tumour burden and pleurodesis success. Further prospective evaluation in a larger cohort is underway. Consistent with the reported literature, we found that mesothelioma has a high failure rate of pleurodesis compared to non-mesothelioma patients. References Rodriguez-Panadero F. Respiration 2012; 83(2): 91–98; Bielsa S. Lung 2011;189(2): 151–155.

An otherwise well, fully immunised 9-year-old boy presented due to systemic malaise with an infected knee laceration 10 days after falling onto concrete in his school playground. On examination his growth parameters were age-appropriate; he was febrile to 39.1℃, with purulent exudate oozing from his knee (figure 1). There was evidence of nodular lymphangitis with lymphocutaneous spread (figure 2). Investigations revealed white cell count of 12.2×109/L with mild neutrophilia (9.37×109/L), C reactive protein of 58 mg/L, and his blood culture was negative. Imaging excluded an underlying bone infection. Figure 1 The …

Groin and axillary lymph node dissections are associated with significant morbidity. Possible complications include lymphangitis, wound dehiscence, lymphocele, hematomas and lymphedema. Secondary lymphedema of the limbs is a debilitating and progressive condition that commonly occurs following melanoma treatment. The technique known as lymphatic microsurgical preventive healing approach (LYMPHA) is able to prevent secondary lymphedema following lymph node dissection. LYMPHA can only be carried out in patients with melanoma of the trunk. From a surgical point of view, it is recommended to perform surgical lymphatic ligatures on cut lymphatic vessels instead of using an electric or bipolar scalpel. Blue dye can be useful in order to visualize the lymphatic vessels and properly close them. Lymphorrhea from the wounds should be always treated initially with compressive dressing. In refractory cases, sclerosing agents can be used or fibrin glue or other synthetic adhesives can be injected. If conservative treatment fails, surgical treatment can be performed. For what concerns lymphedema, non-operative techniques make it possible to control the evolution of the pathology and reduce the stage of already advanced cases. Therapeutic strategies consist of bandages and compression garments. Multiple lymphatic-venous anastomoses have proved to be effective in the treatment of secondary peripheral lymphedema.

Pyemotes ventricosus is a free-living mite feeding on larvae or nymphs of insects, including moths, beetles, wasps and bees, that are usually found in grain, straw and firewood. When present in great number or when its food is lacking, it could accidentally bite mammals, including humans, causing a highly pruritic self-limiting dermatitis, sometimes followed by a lymphangitis known as "comet sign".We present a singular case of mite lymphangitis that surrounds and delimitates breast prosthesis in a 30-year-old Caucasian woman. Other bite in the lower abdomen did not present comet sign. The patient got the infestation in her vacation home in the South of Italy, uninhabited for 10 months since COVID-19 confinement. We hypothesize that the previous surgery made the lymphatic vessels more prone to inflammation and we compare other insect bites that can occur vacationing in a long period uninhabited room.A delayed diagnosis of comet sign implies a retarded fumigation allowing new mite bites and, in this case, extends the patient's preoccupation about the prosthesis rejection.

Background: Trimeresurus stejnegeri stejnegeri bite induces tissue swelling, pain, thrombocytopenia, rhabdomyolysis, and acute renal failure. However, the incidence of coagulopathy, factors associated with wound necrosis, and the appropriate management of this condition have not been well characterized yet. Materials: This study included patients bitten by T. s. stejnegeri that were admitted to the study hospitals from 2001 to 2016. Patient characteristics, laboratory data, and management approaches were compared in victims with and without wound necrosis. Results: A total of 185 patients were evaluated: three patients (1.6%) were asymptomatic; whereas tissue swelling and pain, local ecchymosis, wound necrosis, coagulopathy, thrombocytopenia, rhabdomyolysis, and renal impairment were present in 182, 53, 13, 15, 10, 1, and 3 patients, respectively. One patient died from coagulopathy and hemorrhagic shock. Antivenom was administered to all envenomed patients at a median time of 1.8 h after the bite. The median total dose of antivenom was five vials. Chi-square analysis showed that bitten fingers, using cold packs during first aid, presence of bullae or blisters, lymphangitis or lymphadenitis, local numbness and suspected infection to be significantly associated with wound necrosis. After adjustment using a multivariate logistic regression model, only cold packs as first aid, bulla or blister formation, and wound infection remained significant. Conclusions: The main effects of T. s. stejnegeri envenomation are tissue swelling, pain, and local ecchymosis. We do not recommend the use of cold packs during first aid to reduce wound pain, as this may be a risk factor for wound necrosis. In addition, patients with bulla or blister formation should be carefully examined for subsequent wound necrosis. Antiplatelet use may worsen systemic bleeding. No severe rhabdomyolysis or renal failure was observed in this large case series, we therefore considered that they were not prominent effects of T. s. stejnegeri bite.

An 83-year-old Japanese tatami craftsman with underlying diabetes mellites who complained of severe pain and feeling of warmth in his right knee, with mild chills. Fluid accumulation was seen in his prepatellar bursa and Staphylococcus aureus was detected in his synovial fluid culture, confirming the diagnosis of prepatellar septic bursitis. Prepatellar bursitis is well known as housemaid's knee, which is caused by inflammation of the prepatellar bursa among people who spend long periods of time kneeling such as housemaids, clergy, and gardeners.

OBJECTIVES: The aim of our study was to investigate the association between driver oncogene alterations and metastatic patterns on imaging assessment, in a large cohort of metastatic lung adenocarcinoma patients. METHODS: From January 2010 to May 2017, 550 patients with stage IV lung adenocarcinoma with molecular analysis were studied retrospectively including 135 EGFR-mutated, 81 ALK-rearrangement, 47 BRAF-mutated, 141 KRAS-mutated, and 146 negative tumors for these 4 mutations (4N). After review of the complete imaging report by two radiologists (junior and senior) to identify metastatic sites, univariate correlation analyzes were performed. RESULTS: We found differences in metastatic tropism depending on the molecular alteration type when compared with the non-mutated 4N group: in the EGFR group, pleural metastases were more frequent (32% versus 20%; p = 0.021), and adrenal and node metastases less common (6% versus 23%; p < 0.001 and 11% versus 23%; p = 0.011). In the ALK group, there were more brain and lung metastases (respectively 42% versus 29%; p = 0.043 and 37% versus 24%; p = 0.037). In the BRAF group, pleural and pericardial metastases were more common (respectively 47% versus 20%; p < 0.001 and 11% versus 3%; p = 0.04) and bone metastases were rarer (21% versus 42%; p = 0.011). Lymphangitis was more frequent in EGFR, ALK, and BRAF groups (respectively 6%, 7%, and 15% versus 1%); p = 0.016; p = 0.009; and p < 0.001. CONCLUSION: The application of these correlations between molecular status and metastatic tropism in clinical practice may lead to earlier and more accurate identification of patients for targeted therapy. KEY POINTS: • Bone and brain metastasis are the most common organs involved in lung adenocarcinoma but the relative incidence of each metastatic site depends on the molecular alteration. • EGFR-mutated tumors preferentially spread to the pleura and less commonly to adrenals, ALK-rearrangement tumors usually spread to the brain and the lungs, whereas BRAF-mutated tumors are unlikely to spread to bones and have a serous (pericardial ad pleural) tropism. • These correlations could help in the clinical management of patients with metastatic lung adenocarcinoma.

Cat bites represent the second most common mammalian bites after dog bites and are responsible for three-quarters of bites that result in infection. We report a case of a 60-year-old retired woman who was admitted to the surgery daily clinic due to fever and pain with three necrotic bite wounds on her hand and lymphangitis, which developed one day after she had been bitten by her cat. Prompt debridement, irrigation and drainage combined with empiric oral amoxicillin/clavulanic acid, resulted in clinical improvement and reduction of elevated inflammatory parameters specifically C-reactive protein. While wound cultures remained sterile, serology results were positive for Bartonella henselae.

The hypoxic patient with a normal chest X-ray can be a diagnostic challenge. This case illustrates the rational diagnostic process and describes a relatively rare but important complication of cancer metastasis. Thrombotic microangiopathy, like lymphangitis carcinomatosa, may cause respiratory failure and is a poor prognostic finding. However, unlike lymphangitis carcinomatosa, it may not have specific findings on cross-sectional imaging.

Crohn’s disease (CD) is a gastrointestinal disorder of unknown etiology. CD-specific longitudinal ulcers show an association between disease pathogenesis and vasculature dysfunction. Granulomatous lymphangitis may also contribute to CD pathogenesis; meanwhile, vasculitis is the primary CD lesion. We investigated the association between granulomas and lymphatic and blood vessels to assess the role of vasculature in CD pathogenesis. Two small and large intestine specimens were obtained from four CD patients. From each specimen, 160 sequential sections were obtained and double immunohistochemical stained to label lymphatic and blood vessels in association with granulomas. We found that 289 of 342 granulomas (85%) were associated with a lymphatic vessel and 313 of 364 granulomas (86%) were associated with a blood vessel. Although intrablood vessel granulomas were not detected, intralymphatic vessel granulomas were. In the internal region of the granuloma, we found more blood vessels than lymphatic vessels. Hence, these results cumulatively demonstrate that CD epithelioid cell granulomas are differentially associated with lymphatic and blood vessels, suggesting both as essential for the formation and maintenance of these granulomas. Moreover, both lymphatic and blood vessels may participate in granulomatous inflammation in the primary CD lesions; however, additional studies with larger numbers of participants are required to validate our findings.

Human living styles and life has been troubled by diabetes for many decades that arises from 451 million patients (ages from 18-99 years) worldwide in 2017

OBJECTIVE To clarify the pathological characteristics of granuloma and granulomatous lymphangitis in patients with non-neoplastic bowel diseases and to compare their significance in the differential diagnosis of Crohn's disease (CD) and intestinal tuberculosis (ITB). METHODS Altogether 78 cases with CD, 11 with ITB and 33 suffering from other non-neoplastic bowel diseases were included. All patients underwent a partial enterectomy and histopathological examination. Pathological sections were reviewed retrospectively. Detailed morphological features and the distribution of granulomas and granulomatous lymphangitis in the three groups were analyzed and compared. RESULTS Significant differences in the features of granuloma were observed in CD compared with ITB, including the presence of Langhans giant cells, caseous necrosis, coalescence, hyaline change, onionskin changes, and their frequency and size. Granulomatous lymphangitis was significantly more frequent in CD than in other non-neoplastic bowel diseases (P