Growth inhibitory effect of selected medicinal plants from Southern Ethiopia on the mycelial phase of Histoplasma capsulatum var. farciminosum.

BACKGROUND: Epizootic lymphangitis is an infectious and chronically debilitating disease of the equines. Histoplasma capsulatum var. farciminosum, a thermally dimorphic fungi, is the causative agent for the disease. In Ethiopia, the disease significantly affects carthorses, posing threats to animal welfare, and resulting in substantial economic losses. Limited availability of widely accessible antifungals in addition to the chronic nature of the disease is the major challenge against management of epizootic lymphangitis. This study aimed to assess the in vitro efficacy of specific local medicinal plant extracts against the mycelial phase development of H. capsulatum var. farciminosum in southern Ethiopia. The leaves of Xanthium strumarium, Kanda (Family Rubiaceae), Croton macrostachyus (Bisana in Amharic), and Centella Asiatica (Echere waye as a local name in Zeyissegna) that are traditionally used for the treatment of different skin ailments were collected and extracted for the in vitro trial. RESULTS: The study revealed that methanol extracts of Xanthium strumarium, Kanda, Croton macrostachyus, and Centella Asiatica, at minimum inhibitory concentrations of 1.25 mg/ml, 2.5 mg/ml, 2.5 mg/ml, and 5 mg/ml, respectively, inhibited the growth of H. capsulatum var. farciminosum. CONCLUSION: This in vitro finding could serve as significant preliminary data in the exploration of effective alternative treatment options for epizootic lymphangitis. This study provides a crucial foundation for further research aimed at determining the chemical components and in vivo effectiveness of these plant extracts against both the mycelial and yeast forms of Histoplasma capsulatum var. farciminosum.

Terapia descongestiva como complemento a la cirugía de anastomosis linfáticovenosas y transferencia de linfonodos vascularizados: Una revisión de la literatura / Decongestive therapy as an adjunct to lymphatic-venous anastomosis surgery and vascularized lymph node transfer: A review of the literature

Resumen Introducción: El linfedema es una enfermedad inflamatoria crónica que afecta cerca de 250 millones de personas en el mundo. El tratamiento tradicional es la terapia descongestiva. Últimamente, existe la opción de complementar el tratamiento tradicional con procedimientos quirúrgicos fisiológicos como anastomosis linfáticovenosas y transferencia de linfonodos vascularizados. Sin embargo, la evidencia del uso de la terapia descongestiva en los cuidados pre y posoperatorios en estas cirugías es limitada. Objetivo: Evaluar el uso de terapia descongestiva como complemento a la cirugía de linfedema mediante anastomosis linfáticovenosas y transferencia de linfonodos vascularizados. Materiales y Método: Se realizó una revisión de la literatura en las siguientes bases de datos: Cochrane, Pubmed y Google académico, utilizando los siguientes términos mesh: "anastomosis, surgical", "lymphedema", "perioperative care", "microsurgery", "rehabilitation", "therapy", "lymph nodes", "bypass", "lymphedema and microsurgery". Se incluyó aquellos artículos que describían el uso de la terapia descongestiva en los cuidados pre- y posoperatorios. Resultados: Se identificó un total de 201 artículos y 12 fueron incluidos en el análisis. La evidencia reporta que las terapias más usadas en el cuidado pre- y posoperatorio son compresión, drenaje linfático manual y tratamientos personalizados. Sin embargo, la mayoría de los autores hace una descripción vaga de las terapias mencionadas. Discusión y Conclusión: La evidencia respecto al uso de terapia descongestiva como tratamiento complementario es débil. Los expertos recomiendan su uso, sin embargo, se necesitan futuras investigaciones que describan el uso de cada uno de sus componentes como complemento de procedimientos quirúrgicos fisiológicos para el manejo del linfedema.

Background: Lymphedema is a disease that affects about 250 million people around the world. The traditional treatment is decongestive therapy. In the past years, there is the option to complementing the traditional treatment with physiological surgical procedures such as lymphatic-venous anastomosis (LVA) and vascularized lymph node transfer (VLNT). However, the evidence for the use of decongestive therapy in pre- and post-operative care in these surgeries is limited. Aim: To evaluate the use of decongestive therapy as a complement to lymphedema surgery such a lymphatic-venous anastomosis and transfer of vascularized lymph nodes. Materials and Method: A literature review was carried out in the following databases: Cochrane, Pubmed and Academic Google, using the following mesh terms: "anastomosis, surgical", "lymphedema", "perioperative care", "microsurgery", "rehabilitation", "therapy", "lymph nodes","bypass", "lymphedema and microsurgery". "Those articles that described the use of decongestive therapy in pre- and post-operative care were included. Results: 201 articles were identified and 12 were included in the analysis. The evidence reports that the most used therapies in pre- and post-operative care are compression, manual lymphatic drainage and personalized treatments. However, most of the authors give a vague description of the mentioned therapies. Discussion and Conclusion: The evidence regarding the use of decongestive therapy as a complementary treatment is weak. Experts recommend its use; however, future research is needed to describe the use of each of its components as a complement to physiological surgical procedures for the management of lymphedema.

In Vitro Evaluation of the Effects of Selected Plants on the Growth of the Mycelial Form of Histoplasma capsulatum Variety farciminosum in Ethiopia.

Epizootic lymphangitis is prevalent in equines in Ethiopia, causing remarkable economic and welfare impacts but often neglected. Lack of effective treatment contributed to its continued occurrence, and hence, search for an effective treatment should be considered a priority area to minimize its impacts. Previous ethnobotanical studies have reported that Curcuma longa, Phytolacca dodecandra, and Datura stramonium were used to treat cutaneous fungal infections and reduce their incidence. The treatment effects of these plants against epizootic lymphangitis should be studied. The in vitro growth inhibitory effects of methanol extracts of the root of C. longa, berry of P. dodecandra, and leaf of D. stramonium were evaluated. Histoplasma capsulatum var farciminosum was isolated from clinical cases of epizootic lymphangitis in carthorses in central Ethiopia. The nested polymerase chain reaction was used to confirm the identity of the isolates. Serial twofold dilutions of the extract of berries of P. dodecandra and leaves of D. stramonium were done in sterile water, whereas dilution of the extract of roots of C. longa was done in dimethylsulphoxide. The effects of the plants on the growth of Histoplasma capsulatum var farciminosum were assessed by agar dilution assay. Culture media with no antifungal agent and media containing ketoconazole served as negative and positive control, respectively. The methanol extract of C. longa showed inhibitory effects at concentrations ranging from 0.07 to 5 mg/mL. Similarly, the methanol extract of P. dodecandra showed growth inhibitory effects at concentrations ranging from 0.156 to 5 mg/mL. That is, the growth inhibitory concentration of C. longa was 0.07 mg/mL, whereas that of P. dodecandra was 0.156 mg/mL. In contrast, D. stramonium showed no inhibitory effect. This preliminary observation showed that methanol extracts of C. longa and P. dodecandra showed inhibitory effects on the growth of Histoplasma capsulatum var farciminosum requiring further repeated in vitro evaluation so as to generate adequate evidence, which would justify in vivo trials.

Barriers to access and re-attendance for treatment of podoconiosis: a qualitative study in northern Ethiopia.

BACKGROUND: Podoconiosis is a chronic non-infectious lymphoedema affecting individuals exposed to red clay soil in endemic areas. Evidence from International Orthodox Christian Charities (IOCC) treatment centers' registers suggests that a significant proportion of registered patients with podoconiosis fail to re-attend for treatment, putting them at risk of worsening disability associated with the lymphoedema and attacks of acute adenolymphangitis. The aim of this study was to explore barriers to access and re-attendance of patients with podoconiosis in northern Ethiopia. METHODS: A cross-sectional qualitative study was conducted at three IOCC treatment sites from February to April 2013. Twenty-eight patients and three project leaders took part in in-depth interviews. Three focus group discussions were undertaken with 22 patients, patient association leaders and project staff members. RESULTS: Barriers to access and to continued attendance at treatment centers were recognized by all participant groups. The following reasons were reported: lay beliefs about the disease's causation and presentation, occupational, geographic and financial barriers, stigma and conflicting expectations of treatment services. CONCLUSIONS: This study illustrates the multiple, step-wise barriers to accessing treatment faced by podoconiosis patients. These factors are dynamic, frequently interact and result from competing social and economic priorities.

Evaluation of berries of Phytolacca dodecandra for growth inhibition of Histoplasma capsulatum var. farciminosum and treatment of cases of epizootic lymphangitis in Ethiopia.

OBJECTIVE: To evaluate the berries of Phytolacca dodecandra (P. dodecandra) for its effect on Histoplasma capsulatum var. farciminosum (HCF) and for the treatment of cases of epizootic lymphangitis (EL). METHODS: Samples were collected from un-ruptured nodules of cases of EL at Debre Zeit and Akaki (central Ethiopia). Mycological culture and isolation of HCF were performed at the Aklilu Lemma Institute of Pathobiology. Phytochemical screening was done for n-butanol extract of P. dodecandra to detect alkaloids, saponins, phenolic compounds and flavonoids. The minimum inhibitory concentrations (MICs) and minimum fungicidal concentrations (MFCs) of aqueous and n-butanol extracts of P. dodecandra against HCF were determined by agar dilution assay. For the in vivo trial, 5% simple ointment was prepared from n-butanol extract and applied topically to 24 (twelve early and twelve moderate) cases of EL. RESULTS: Phytochemical screening showed that n-butanol extract of P. dodecandra was positive for alkaloids, saponins and phenolic compounds but negative for flavonoids. The MICs of n-butanol and aqueous extracts of P. dodecandra were (0.039%-0.078%) and (0.625%-1.250%), respectively. The MFCs of n-butanol and aqueous extracts of P. dodecandra were (0.078%-0.156%) and (1.250%-2.500%), respectively. The MIC and MFC of ketoconazole (positive control) was (1.200×10(-5)%-2.500×10(-5)%) and (5.000×10(-5)%-1.000×10(-4)%), respectively while growth was observed on free medium (negative control). From the total of 24 treated cases of EL, 14 (58.3%) responded to treatment; however, 10 (41.7%) did not respond to treatment. There was no significant difference in the degree of response to treatment between early and moderate cases (χ(2)=0.686; P=0.408). CONCLUSIONS: It can be concluded that n-butanol extract of P. dodecandra demonstrates antifungal effects while the aqueous extract shows no antifungal activity.

Rapid community identification, pain and distress associated with lymphoedema and adenolymphangitis due to lymphatic filariasis in resource-limited communities of North-eastern Nigeria.

Identification of communities with people that could benefit from adenolymphangitis (ADL) and lymphoedema morbidity management within Lymphatic Filariasis Elimination Programmes (NLFEP) in many African countries is a major challenge to programme managers. Another challenge is advocating for proportionate allocation of funds to alleviating the suffering that afflicted people bear. In this study we developed a rapid qualitative technique of identifying communities where morbidity management programme could be situated and documenting the pain and distress that afflicted persons endure. Estimates given by health personnel and by community resource persons were compared with systematic household surveys for the number of persons with lymphoedema of the lower limb. Communities in Northeastern Nigeria, with the largest number of lymphoedema cases were selected and a study of local knowledge, physical, psychosocial burden and intervention-seeking activities associated with the disease documented using an array of techniques (including household surveys, key informant interviews, group discussions and informal conversations). Health personnel gave a more accurate estimate of the number of lymphoedema patients in their communities than either the community leader or the community directed ivermectin distributor (CDD). Community members with lymphoedema preferred to confide in health personnel from other communities. The people had a well developed local vocabulary for lymphoedema and are well aware of the indigenous transmission theories. Although the people associated the episodic ADL attacks with the rains which were more frequent at that period they did not associate the episodes with gross lymphoedema. There were diverse theories about lymphoedema causation with heredity, accidental stepping on charmed objects and organisms, breaking taboos. The most popular belief about causation, however, is witchcraft (60.9%). The episodic attacks are dreaded by the afflicted, since they are accompanied by severe pain (18%). The emotional trauma included rejection (27.5%) by family, friends and other community members to the extent that divorce and isolation are common. Holistic approach to lymphoedema morbidity management should necessarily be an integral component of the ongoing transmission elimination programme. Any transmission prevention effort that ignores the physical and psychological pain and distress that those already afflicted suffer is unethical and should not be promoted.

[Treatment of limbs lymphedema]. / Traitement des lymphœdèmes des membres.

The treatment of lymphedema aims to reduce the volume and prevent infectious and joints mobility complications. This treatment rarely cure and is usually symptomatic; thus it should be continued throughout the life. The erysipelas and lymphangitis are common complications of lymphedema. Erysipela is always of streptococcal origin and requires systemic antibiotics. The risk of recurrent erysipelas on lymphedema is high. In case of large swelling associated with significant dermal sclerosis, it may lead to decrease joint mobility and functional impairment. The skin cares, manual lymph drainage, compression therapy with bandages and exercises are the four pillars of the complex decongestive therapy of limb lymphedema. Compression is the most important treatment. Lymphedema can be improved by only bandages, but a sustained improvement of lymphedema cannot be seen without bandages. The effectiveness of treatment must be evaluated by objective methods, measuring the perimeters of members or volumes. The management of lymphedema includes three phases: attack or initial treatment that aims to reduce volume of the lymphedema and maintenance phase to maintain the result and finally withdrawal phase. In the attack phase, we use complex decongestive therapy, mainly multilayer inelastic bandaging and manual lymphatic drainage (MLD). In the maintenance phase, we use elastic compression (stockings or sleeves) possibly associated with MLD. At all stages skin care and exercises are used. Adjuvant treatments may be useful (intermittent pneumatic compression, drug treatment). Surgery is rarely used except for genital lymphedema. The therapeutic management of lymphedema is difficult but has a variety of techniques. The complex decongestive therapy is very effective to restore a better quality of life even though it does not provide a cure for lymphedema.

WITHDRAWN: Antibiotics / anti-inflammatories for reducing acute inflammatory episodes in lymphoedema of the limbs.

BACKGROUND: Lymphoedema is a chronic, progressive condition and one area of debate is the optimum management for infective/inflammatory episodes (AIE's). OBJECTIVES: To determine whether antibiotic/anti-inflammatory drugs given prophylactically reduce the number and severity of AIE's in patients with lymphoedema. SEARCH STRATEGY: We searched the Cochrane Breast Cancer Group register in September 2003, the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003), CINAHL, MEDLINE, PASCAL, SIGLE, UnCover, reference lists produced by The British Lymphology Society, the National Research Register (NRR) and the International Society of Lymphology congress proceedings. SELECTION CRITERIA: Randomised controlled trials testing an antibiotic or anti-inflammatory drug against placebo (with or without physical therapies) were included. DATA COLLECTION AND ANALYSIS: Eligibility for inclusion was confirmed by two blinded reviewers. The papers were screened independently using a checklist of criteria relating to quality. Both reviewers extracted data from the eligible studies using a data extraction form. MAIN RESULTS: Four studies (364 randomised patients) were included. Two studied the effects of intensive physical treatment plus selenium or placebo in preventing AIE's, and two studied the effects of Ivermectin, Diethylcarbamazine (DEC) (anti-filarial agents) and penicillin as prophylactic treatment for adeno lymphangitis(ADL) versus placebo.Both selenium trials reported no inflammatory episodes during the trial period in the treated group but one case of infection in the two placebo groups respectively. Seven additional cases of infection in trial one and 14 cases in trial two required treatment in the three month follow up period.One anti-filarial trial reported 127 ADL episodes for all groups during the treatment year (compared with 684 episodes during the pre-treatment year). There were 228 ADL episodes during the trial follow-up year but no findings were significant. No link was found between the grade of oedema and the frequency of ADL episodes. There was a significant link between increased episodes and the rainy season. Penicillin reduced the mean number of inflammatory episodes from 4.6 to 0.5 after treatment, which increased to 1.9 at the end of follow-up. AUTHORS' CONCLUSIONS: The effectiveness of selenium in preventing AIE in lymphoedema remains inconclusive in the absence of properly conducted randomised-controlled trials. Anti-filarials do not appear to reduce ADL episodes in filarial lymphoedema. Penicillin appears to contribute to a significant reduction in ADL when combined with foot-care. The importance of foot-care should be recommended, which may also apply to care of the arm following breast cancer treatment. Properly conducted trials are needed to demonstrate any efficacy of these interventions.

[A case of diffusely infiltrating rectal cancer with pulmonary lymphangitis carcinomatosa successfully treated with mFOLFOX6 chemotherapy as salvage].

We report a case of diffusely infiltrating rectal cancer with pulmonary lymphangitis carcinomatosa that responded to mFOLFOX6 chemotherapy and enabled survival for 19 months. A 68-year-old man was admitted to our hospital for a dry cough and dyspnea. Chest X-ray and CT examination revealed prominent pulmonary markings and abnormal infiltrating shadows. Interstitial pneumonia was suspected, and we started treatment with steroid medication, but this had no effect. A colonoscopy and barium enema revealed diffusely infiltrating rectal cancer. Abdominal CT and PET showed lymphangitis carcinomatosa of the lung, paraaortic lymph node swelling, and left hydronephrosis due to rectal cancer. The patient was diagnosed with stage IV rectal cancer. Thus, a curative operation was deemed impossible. Because of subileus, we performed a decompression loop colostomy in the transverse colon, and started treatment with mFOLFOX6 chemotherapy as salvage in spite of the patient's poor respiratory condition. Though the patient's tumor markers were very high (CEA 107 ng/mL, CA19-9 7,940 U/mL) prior to chemotherapy, they decreased dramatically (CEA 49.7 ng/mL, CA19-9 772 U/mL), and subjective symptoms (dry cough and dyspnea) also improved after 2 courses. After 3 courses of treatment the patient was discharged. After 7 courses, pulmonary markings and abnormal infiltrating shadows had disappeared on chest X-ray and CT. This condition was maintained for 19 months by ambulant chemotherapy without sacrificing high quality of life. Thus, mFOLFOX6 chemotherapy could be an effective salvage regimen in cases of diffusely infiltrating rectal cancer with pulmonary lymphangitis carcinomatosa.

[A case of recurrent breast cancer with life-threatening multiple lung metastasis markedly responding to CMF as third-line chemotherapy].

A 35-year-old woman with taxane and anthracycline-resistant recurrent breast cancer with multiple lung metastasis and carcinomatous lymphangitis was treated with CMF as third-line chemotherapy. A complete response was achieved,and the toxicities were tolerable. We thought that CMF could be a useful regimen as third-line chemotherapy for metastatic breast cancer.

[Nocardia brasiliensis leg ulcer and nodular lymphangitis in France]. / Ulcère de jambe et lymphangite nodulaire à Nocardia brasiliensis en France métropolitaine.

INTRODUCTION: Nocardia brasiliensis is a very rarely reported cause of chronic phagedenic ulcerations. We report the case of an elderly woman who developed such an infection after falling on her right leg on the road in the Bresse country (an essentially agricultural and bovine-cattle breading region) and developed a chronic phagedenic ulcer secondarily complicated by nodular lymphangitis of the thigh. CASE REPORT: A 75 year-old woman fell on her right leg on the side of the main road outside her hamlet in the Bresse country and secondarily developed a chronique phagedenic ulceration. We first considered her as suffering from pyoderma gangrenosum. A complete scanning only revealed an autoimmune thyroiditis and a rapidly healing gastric ulceration, and none of the treatments, either local or systemic, helped the skin condition to heal. After 3 weeks of application of a local corticoid ointment, the patient developed fever, general malaise, an exacerbation of her wound and an infiltration of the skin round her knee, together with nodular lymphangitic dissemination. A supplementary bacterial swab disclosed massive proliferation of a slow-growing Gram-positive bacillus, which proved to be Nocardia brasiliensis, together with a methicillino-sensitive Staphylococcus aureus. The treatment with sulfamethoxazole-trimetoprim gave a rash after 12 hours and was changed to amoxicillin and clavulanic acid, which rapidly proved to be permanently effective. DISCUSSION: The revelation of this particular slow-growing bacteria is difficult and requires bacterial swabs. Nocardia brasiliensis is relatively rare in primary skin ulcerations and we discuss the reasons why an elderly women should find this bacteria on the road outside her hamlet in the French countryside. This particular infectious condition requires general scanning, to make sure that the primary skin condition does not extend to other organs. We review the therapeutical options for patients who exhibit allergic reactions to the classically effective antibiotic drugs.

Minimal invasive lymphaticovenular anastomosis under local anesthesia for leg lymphedema: is it effective for stage III and IV?

This is the first report on the effectiveness of minimal invasive lymphaticovenular anastomosis under local anesthesia for leg lymphedema. Fifty-two patients (age: 15 to 78 years old; 8 males, 44 females) were treated with lymphaticovenular anastomoses under local anesthesia and by postoperative compression using elastic stockings. The average duration of edema of these patients before treatment was 5.3 +/- 5.0 years. The average number of anastomosis in each patient was 2.1 +/- 1.2 (1-5). The patients were followed for an average of 14.5 +/- 10.2 months, and the result were considered effective (82.5%) even for the patients with stage III (progressive edema with acute lymphangitis) and IV (fibrolymphedema), but others showed no improvement. Among these cases, 17 patients showed reduction of over 4 cm in the circumference of the lower leg. The average decrease in the circumference excluding edema in bilateral legs was 41.8 +/- 31.2% of the preoperative excess length. These results indicate that minimal invasive lymphaticovenular anastomosis under a local anesthesia is valuable instead of general anesthesia.

Antibiotics / anti-inflammatories for reducing acute inflammatory episodes in lymphoedema of the limbs.

BACKGROUND: Lymphoedema is a chronic and progressive condition and current debate revolves around the best course of management for infective/inflammatory episodes. OBJECTIVES: To determine whether antibiotic/anti-inflammatory drugs given prophylactically reduce the number and severity of infective/inflammatory episodes in patients with lymphoedema. SEARCH STRATEGY: We searched the Cochrane Breast Cancer Group register in September 2003, the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003), CINAHL, MEDLINE, PASCAL, SIGLE, UnCover, reference lists produced by The British Lymphology Society, the National Research Register (NRR) and the International Society of Lymphology congress proceedings. SELECTION CRITERIA: Types of studies considered for review were randomised controlled trials testing an antibiotic or anti-inflammatory drug against placebo (with or without physical therapies). DATA COLLECTION AND ANALYSIS: Eligibility for inclusion was confirmed by two blinded reviewers who screened the papers independently using a checklist of criteria relating to the randomisation and blinding of a trial. Both reviewers extracted data from the eligible studies using a data extraction form. MAIN RESULTS: Overall, four studies (364 randomised patients) were included. Two of these studied the effects of intensive physical treatment plus selenium or placebo in preventing AIE, and two studied the effects of Ivermectin, Diethylcarbamazine (DEC) (anti-filarial agents) and penicillin as prophylactic treatment for adeno lymphangitis(ADL) versus placebo. Both selenium trials reported no inflammatory episodes during the trial period in the treated group but one case of infection in the two placebo groups respectively during the first three weeks of each trial. Seven additional cases of infection in trial one and 14 cases in trial two required treatment in the three month follow up period. One anti filarial trial reported a total of 127 ADL episodes for all groups during the treatment year (compared with 684 episodes reported for the same participants during the pre-treatment year). Another 228 ADL episodes were reported during the trial follow-up year but no significant differences were found between the three groups. No apparent link was found between the grade of oedema and the frequency of ADL episodes. However, there was a significant link between increased episodes and the rainy season. In the penicillin group the mean number of inflammatory episodes was reduced from 4.6 to 0.5 after treatment and increased to 1.9 at the end of the follow-up year. REVIEWERS' CONCLUSIONS: The effectiveness of selenium in preventing AIE in lymphoedema remains inconclusive in the absence of properly conducted randomised controlled trials. Anti-filarials (DEC and Ivermectin) do not appear to reduce ADL episodes in filarial lymphoedema. Foot care may be important in reducing ADL episodes, and penicillin appears to contribute to a significant reduction in ADL, when combined with foot-care. It seems reasonable to emphasise the importance of foot-care to patients and practitioners in preventing infection and this may also apply to care of the arm in women who develop lymphoedema following breast cancer treatment. However, properly conducted trials are needed to demonstrate any efficacy of these interventions.

Cause and Treatment of Lymphedema

INTRODUCTION: Lymphedema develops due to the abnormality of the transport capacity of the lymphatic system. Clinically lymphedema is not only a cosmetic deformity, but also a disabling and distressing condition. CLASSIFICATION: Primary lymphedema is an inborn defect caused by such condition as absence or underdevelopment of the lymphatic system. It occurs in approximately 1 in 10,000 persons less than 20 years of age, with females being affected more frequently than males. Secondary lymphedema is an acquired condition resulting from loss or obstruction of the previously normal lymphatic system due to infection, tumor, filariasis and other miscellaneous conditions. CLINICAL FEATURES: Clinical symptoms and signs depend on the duration and the severity of the lymphedema. In the early stage of disease, the edema is soft and pits easily with pressure (pitting edema) and may decrease or disappear with elevation of the limbs. In the advanced stage, the skin texture turns woody as the surrounding tissue becomes indurated and fibrotic. DIAGNOSIS: Lymphangiography was introduced in the early 19th century. But there are several drawbacks to this procedure, including the complexity of the procedure, irradiation by contrast agent that may result in lymphangitis and potentially worsen the lymphedema. Lymphoscintigraphy is easier to perform than lymphangiography and is not reported to cause lymphangitis. Lymphoscintigraphy is gradually replacing lymphangiography. TREATMENT: The mainstay of the treatment is complex decongestive physical therapy including leg elevation, elastic or rigid compression, manual lymph drainage, and intermittent pneumatic compression. When the function of the limb is significantly impaired, surgical reduction is considered. The surgery is not curative, but it can make the disorder more manageable by complex decongestive physical therapy.

Acute lymphangitis treated by moxibustion with garlic in 118 cases.

TCM holds that acute lymphangitis is pathogenically caused by the accumulated internal fire and toxicity, and the external skin injury-induced infection, leading to toxicity going upward along the meridians. The treatment should be given to clear away heat and toxin. Blood letting by a three-edged needle may promote qi and blood circulation and remove the toxic heat. Garlic has the function of antagonizing Staphylococcus aureus, Bacillus dysenteriae and various kinds of bacteria. Since the volatile oil in moxa is antagonistic to bacteria, the burning moxa can also promote the local flow of qi and blood, and enhance the antagonistic effect of garlic on bacteria. Therefore, satisfactory curative results can be achieved by the therapy.

Acute lymphangitis mimicking mechanical neck pain.

OBJECTIVE: To discuss acute lymphangitis as a potentially serious infection that can mimic mechanical musculoskeletal pain. CLINICAL FEATURES: A 27-year-old male plant worker had right-sided neck pain. Numerous lesions on the patient's scalp were observed, but were not considered to be related to the chief complaint. INTERVENTION AND OUTCOME: Conservative therapy was initiated to address what was thought to be mechanical neck pain. Shortly after the initial visit, it became evident that the source of the neck pain was infection because lymphangitis developed. Antibiotic therapy was initiated and complete resolution of the complaint occurred within 1 week. CONCLUSION: Primary contact practitioners should consider all aspects of the patient history and physical findings when formulating a diagnosis. This is especially important in the case of patients presenting with lymphangitis because mismanagement could have serious consequences. The importance of a good patient history and team approach to care is demonstrated by this case.

Respiratory failure due to pulmonary lymphangitis carcinomatosis.

A man with primary lung cancer developed respiratory failure due to lymphangitis carcinomatosis that was diagnosed by transbronchial lung biopsy specimen. After combination chemotherapy with high-dose etoposide and cisplatin (CDDP), he was able to cease oxygen therapy and showed improvement of his lymphangitis carcinomatosis. He received a total dose of 13,400 mg/m2 of etoposide. This case suggested that respiratory failure due to lymphangitis carcinomatosis can be a treatable condition.