Lymphedema and Cellulitis

We-survivors know the story. First you find the lump, then go through surgery, irradiation, chemotherapy, depending on its kind. Once it is all finished, you hope that’s it, you can breathe again. As in some war movies where bombs are falling, shootings, screams, and then it’s all quiet again. Unfortunately, if lymph nodes have been removed or irradiated (because they might harbor some cancer cells) then lymphedema may raise its head, sometimes soon after surgery, but othertimes years later. There is no cure but it can be managed.

What is Lymphedema: The arteries bring blood, with oxygen and nutrients to the tissues, including the spaces between the cells (interstitial spaces). From there the fluid goes to veins that carry the waste away. There is excess fluid between the two, which collects in the “lymphatic” vessels. This fluid that filters out of the blood circulation contains proteins, but also cellular debris, bacteria, etc. Once inside the lumen of the lymphatic vessels, the fluid is guided along increasingly larger vessels to lymph nodes, which remove debris and police the fluid for dangerous microbes. The lymph ends its journey in the thoracic duct which drains into the blood circulation. If there is damage to the lymphatics, ie if some or all lymph nodes in the armpit have been removed surgically or irradiated because they may hide some cancer cells in them, then the lymph has nowhere to go and an abnormal amount of protein-rich fluid collects in the arm. Left untreated, this stagnant fluid causes tissue channels to increase in size and number, reducing oxygen availability. This interferes with wound healing and provides a rich culture medium for bacterial growth that can result in an infection (cellulitis). In roughly half the cases where the lymph nodes have been removed lymphedema may develop.

The swelling by itself may not matter much. I just made my shirt-sleeves wider. But, preventing an infection is very important. If it is left untreated, cellulitis can result in gangrene and amputation (!), but also a delay in treatment will cause further damage to the lymphatic system and set up a vicious circle. To reduce the swelling, you may need compression bandaging, gloves and sleeves, special massage and exercises, also good skin care, to increase the skin’s natural defences. Also, avoid heat and the sun and wear compression sleeves if you fly in an airplane. Sometimes the episodes are mild, starting from a tiny speck on the arm. A mosquito bite is enough to do it, or a tiny scrape eg as you are trying to put the compression sleeve on, but sometimes the compression itself may trigger it.

If you detect any signs of infection, ie redness, swelling, pain, fever, you have to go to the Emergency right away. It is best to always have some antibiotics with you (eg Cephalexin) to take ASAP. Depending on the Emergency doctors’ evaluation, you may be given oral or more likely intravenous antibiotics. Cellulitis is caused by Group A Streptococci, but sometimes Staphylococcus Aureus.

Early diagnosis of cellulitis is important. But if you get a dime-size red speck, should you run to the Emergency or not? What you can do is, mark the edge of the red with a pen and wait for half an hour or so. If it is cellulitis then the red will cross the line and get bigger. But the red may be a false alarm too, it may get paler and fade in the background. If the red patch gets bigger, go to Emergency right away. As a general rule, if you get two bouts of cellulitis in a year, you may be given antibiotics prophylactically.

I had cellulitis requiring intravenous antibiotics twice. Going to Emerg in the middle of the night is no picnic. After the first time, my family doctor gave me a letter describing the situation, that I have lymphedema after breast cancer surgery and that I may have cellulitis ie it is not just a rash, to save time in diagnosis. The letter was very helpful and I am grateful to him for this! I was given Ancef, then Ancef plus Ceftriaxone antibiotics intravenously for 5 days, then oral Cephalexin for a month or so. Then I was given Cephalexin prophylactically, half the therapeutic dose, ie 2 x 500mg. I have to say that the infection is gone – for now at least. I will keep taking it, especially during the summer when my arm swells with the heat and as the wraps hold it down, the danger of infection is increased.

Of course, your doctor will decide what antibiotics to use, depending on possible allergies, severity of symptoms and other factors, but the following link is a consensus document on the management of cellulitis in lymphedema, from the British Lymphology Society, to give you an idea.

lymphoedema.org/images/pdf/CellulitisConsensus.pdf

Leda Raptis, March 2018