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Linear erythematous rash over the trunk

This is a diagnosis of superficial lymphangitis secondary to an insect bite. This is based on the observation of a punctum at the original eruption site on her trunk with a linear erythematous streak which followed the pathway of the superficial lymphatic drainage, proximally, towards the regional affected lymph nodes. Superficial lymphangitis is mainly caused by inflammation of the lymphatic vessels and oedema of the surrounding tissue. The most common aetiology of this phenomenon is bacterial infection. However, there are other non-bacterial entities to this as well, examples being arthropod bites and iatrogenic procedures. A toxic, allergic, viral or fungal agent can enter the skin and travel to the superficial lymphatic channels which are situated in the deep dermis and subdermal tissues. The erythema streaking seen in this child started from the level of her umbilicus and ran superiorly towards the anterior or pectoral axillary lymph nodes and a small portion to the parasternal lymph nodes. Within a few days, the inflammation of these vessels will usually subside and progress to post-inflammatory skin changes. Awareness by physicians about non-infectious causes for lymphangitic streaking is important as they looks similar to those caused by bacterial infections. A high index of suspicion for nonbacterial superficial lymphangitis should arise when the lesion evolves with erythematous streaks following a geographical pathway of the superficial lymphatic drainage of the area in the absence of fever or lymph node enlargement on clinical examination. Antibiotics are therefore not always indicated, but serial assessments with photographic images and markers are useful to monitor for regression or progression and may give an indication to the clinician as to whether more aggressive treatment is required or not. This child remained well subsequently. On the 4-week review, the rash had almost completely resolved (Fig. 1d).