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May 2020     Volume 4 Issue 3 
 

Copyright 2020 The National Society for Cutaneous Medicine 292 

SHORT COMMUNICATIONS 
 

 

Herpes Simplex Masquerading as Bacterial Lymphangitis 
 
Pooja R. Shah, MD1, Fatema S. Esaa, BA2, Lisa A. Beck, MD1 

1Department of Dermatology, University of Rochester Medical Center, Rochester, NY 
2University of Rochester School of Medicine and Dentistry, Rochester, NY 
 

 
 
 

A 46-year old healthy Caucasian female with 
a history of Crohn’s disease (currently in 
remission) presented to the emergency 
department with a 2-week history of painful 
and pruritic rash affecting the right 5th finger, 
upper extremity, and neck. Pruritis began 
initially ten days prior to presentation. 
Subsequently, three days prior to 
presentation, patient experienced sudden 
onset pain and erythema of the right 5th finger 
with progression along her right forearm. She 
noted that her symptoms were worsening but 
was not able to identify any alleviating or 
aggravating factors. Extensive review of 
systems was otherwise negative, except for 
lymphadenopathy. She denied recent travel 
or exposure to raw foods, poison ivy, rose 
bushes, rodents, or new medications; 
however, she noted that she lived in a barn 
and had direct contact with horses, cats, and 
dogs.  
 
Physical exam was notable for a very painful, 
ulcerated pink plaque with serosanguinous 
crust and surrounding erythema with few 
pustules at the periphery on the right anterior 
neck. On the right distal dorsal 5th finger, 
there was a hemorrhagic bulla with prominent 
erythema accompanied by a linear 
erythematous streak extending proximally 
(Figure 1 A-C). She had painful enlarged 
lymph nodes in her right submandibular and 

axillary regions. The patient was treated 
empirically with oral clindamycin and 
azithromycin for possible bacterial infection, 
resulting in only partial clinical response. 
There was significant reduction in erythema 
and pain, but persistent itch and burning. 
 
Figure 1.  
(A) On physical exam there was a very painful, 
ulcerated pink plaque with serosanguinous crust and 
surrounding erythema and peripheral pustules on the 
right anterior neck. 

 
A 



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May 2020     Volume 4 Issue 3 
 

Copyright 2020 The National Society for Cutaneous Medicine 293 

(B) On the right distal dorsal 5th finger, there was a 
hemorrhagic bulla with prominent erythema.  
(C) Accompanied by a linear erythematous streak 
extending proximally. 
 

 
 

CBC, CMP, and ESR were unremarkable. 
Chest x-ray was negative. Bacterial culture 
from the finger lesion was positive for 3+ 
MSSA and non-hemolytic Streptococcus. 
Viral PCR from finger lesion was positive for 
HSV1. Bartonella serology was negative. The 
patient subsequently responded very well to 
oral valacyclovir with complete resolution. 
 

Lymphangitis is inflammation along the 
lymphatic channels that occurs as a result of 
infection at a distal site, most commonly 
observed in the setting of acute bacterial 
infections such as Group A Beta-
Hemolytic Streptococcus, Staphylococcus 

aureus, Pseudomonas, and Pasteurella 
multicoda. Consequently, the presence of 
lymphangitic streaking often results in 
treatment with systemic antibiotics. However, 
superficial lymphangitis may also occur 
secondary to nonbacterial etiologies 
including viral or fungal infections, arthropod 
bites, or iatrogenic interventions.1 

Although the natural history of herpes 
simplex lymphangitis is self-resolution, 
antiviral therapy may shorten the duration of 
symptoms and help prevent recurrence.2 Our 
patient demonstrates a unique case of 
cutaneous herpes simplex infection with 
centrifugal spread complicated by 
lymphangitis and regional lymphadenopathy. 
Awareness of nonbacterial causes of 
lymphangitis will help prevent misdiagnosis, 
unnecessary antibiotic use, and the delay of 
appropriate treatment. 
 
Conflict of Interest Disclosures: None 
 
Funding: None 
 
Corresponding Author: 
Pooja R. Shah, MD 
University of Rochester Medical Center 
Department of Dermatology 
601 Elmwood Ave, PO Box 697 
Rochester, NY 14642  
Email: pshah12@northwell.edu  

References: 
1. Cohen, B.; Nagler, A., & Pomeranz, M. (2016) 

Nonbacterial Causes of Lymphangitis with 
Streaking, Journal of the American Board of 
Family Medicine, 29 (6). 

2. Sands M, Brown R. Herpes Simplex 
Lymphangitis: Two Cases and A Review of the 
Literature. Arch Intern Med. 1988;148(9):2066–
2067. 
doi:10.1001/archinte.1988.00380090126029 

  

B C 

mailto:pshah12@northwell.edu
mailto:pshah12@northwell.edu