Erythema nodosum - a review of an uncommon panniculitis

Panniculitis, inflammation of the subcutaneous fat, is a relatively uncommon condition that usually presents with inflammatory nodules or plaques. Erythema nodosum (EN) is clinically the most frequent form of panniculitis and is considered a reactive process that may be triggered by a wide variety of stimuli. Whilst up to 55% of EN is considered idiopathic, the most common causes include infections, drugs, systemic illnesses such as sarcoidosis and inflammatory bowel disease, pregnancy, and malignancy. EN typically presents in the teens and 20s, and is seen more commonly in females. It is often preceded by a non-specific prodrome of one to three weeks, which may include fever, malaise, and symptoms of an upper respiratory tract infection. Cutaneous lesions then follow, typically localized on the extensor aspect of the limbs. The lesions are painful rounded or oval, slightly raised, non-ulcerative red nodules. The exact pathogenesis of EN is not understood, although is thought to result from deposition of immune complexes in the venules of the septae in subcutaneous fat, causing a neutrophilic panniculitis. The classical histopathological picture is of a septal panniculitis without vasculitis. However, the pathological features vary with the chronology of the lesions. Even without specific therapy for a causative condition, EN typically resolves without treatment. Therefore, symptomatic support is adequate for the majority of patients.

Erythema nodosum in children: evaluation of 39 patients

Erythema nodosum (EN) has been associated with various infectious and noninfectious diseases. A total of 39 EN patients seen between May 2005 and February 2012 were evaluated retrospectively in this study. The etiology of EN was established in 22 of the 39 children (56.4%). Streptococcal infection was the most common cause (23%), followed by tularemia (10.2%) and tuberculosis (latent tuberculosis infection (LTBI) 5%, pulmonary tuberculosis 2.5%). Miscellaneous conditions were as follows: Behçet disease (2.5%), cytomegalovirus (CMV) (2.5%), Giardia lamblia infection (2.5%), and sarcoidosis (2.5%). Four cases had double diagnoses as follows: streptococcal infection plus Mycoplasma pneumoniae, streptococcal infection plus LTBI, streptococcal infection plus Chlamydophila pneumoniae, and tularemia plus LTBI. Streptococcal infections are the most common causative factors of EN among children in our setting. In some cases, either of two diagnoses may induce EN. Etiologic factors should be investigated for the diagnosis and specific treatment of the underlying diseases.

Concomitant occurrence of pyoderma gangrenosum and erythema nodosum in inflammatory bowel disease

Erythema nodosum and pyoderma gangrenosum are common skin manifestations in inflammatory bowel diseases. Curiously, these two cutaneous features have seldom been reported to occur simultaneously. We present three patients affected with inflammatory bowel disease with concomitant erythema nodosum and pyoderma gangrenosum.

[Acute arthritis in sarcoidosis: Löfgren's syndrome]

Sarcoidosis is a systemic inflammatory disease usually presenting with pulmonary symptoms. However, acute arthritis could be the presenting sign of sarcoidosis. We present a 47-year-old man with bilateral arthritis of the ankles, erythema nodosum and bilateral hilar adenopathy on the chest X-ray. This triad is known as Löfgren's syndrome, a form of acute sarcoidosis. He was first treated with an NSAID, followed by a short course of prednisone because of persisting symptoms. After six weeks the patient was asymptomatic. Further investigation showed no decline in pulmonary function. Acute arthritis in patients with sarcoidosis with or without the complete Löfgren's syndrome has a good prognosis. Usually the signs and symptoms will disappear within a few months. Unlike other forms of sarcoidosis, Löfgren's syndrome does not require histological proof of non-caseating granulomas.

Erythema nodosum

Erythema nodosum is an acute inflammatory dermatosis characterized by painful nodules which are generally symmetrical and non ulcerative and are mainly located to the extensor surface of the lower legs. The nodules, due to septal panniculitis, are often accompanied by fever and resolve without permanent sequelae. Arthralgia occurs in more than 50% of patients and begins during the eruptive phase or precedes the eruption by 2-4 weeks. Erythema nodosum is presumed to be a hypersensitivity reaction and may occur in association with several systemic diseases or drug therapies, or it may be idiopathic. The most common cause of erythema nodosum is streptococcal infection in children and streptococcal infection and sarcoidosis in adults. Peak incidence occurs at age 18-34 years. Age and sex distributions vary according to etiology and race; women are affected more often than men. It is possible to distinguish between an acute and a chronic form of erythema nodosum; in the acute form, an early stage and a late stage can be detected, both clinically and histologically. Laboratory and instrumental examinations to be performed in case of erythema nodosum are varied and are intended to identify any underlying trigger disease. Erythema nodosum is a self-limited disease, so the therapy is often only symptomatic. Even if the erythema nodosum quickly responds to systemic steroids, in most cases their use is not recommended, nor necessary; is usually sufficient to use NSAIDs (eg, acetyl salicylic acid, ibuprofen, naproxen, indomethacin).

Erythema nodosum and pernicious anemia

Erythema nodosum (EN) often presents as a sudden onset of tender, erythematous, subcutaneous nodules on the legs and ankles. Although rare, pernicious anemia may be related to vitamin B12 deficiency. Discussion of this association in the context of a particular patient is presented.

Etiology and therapeutic management of erythema nodosum during pregnancy: an update

Erythema nodosum (EN) is the most common form of panniculitis. It is characterized by erythematous, raised, tender nodules that usually occur bilaterally on the extensor surfaces of the lower extremities. EN is associated with many underlying conditions including infection, sarcoidosis, malignancy, and pregnancy. Its underlying etiology, however, is unknown in up to half of cases. Pregnancy is thought to create an optimal background for EN to develop, although the exact mechanisms are unclear. Immune complexes may play a role in the pathogenesis of EN during pregnancy, or EN may be a hypersensitivity reaction to either estrogens or progesterone. EN is a self-limiting process, and non-pharmacologic means such as bed rest and elastic web bandages may be sufficient to control the symptoms. Potassium iodide, systemic and intralesional corticosteroids, non-steroidal anti-inflammatory drugs, salicylates, tumor necrosis factor-α inhibitors, hydroxychloroquine, colchicine, and dapsone are other treatment options available, but some of these drugs are contraindicated in pregnancy while others are considered safe. Before prescribing one of these treatments to a pregnant patient, the patient's obstetrician should be consulted, and a careful risk-benefit analysis should be performed.

Behçet’s disease complicated by multiple aseptic abscesses of the liver and spleen

Aseptic abscesses are an emergent entity and have been described in inflammatory bowel disease, especially in Crohn’s disease, and in other diseases. However, aseptic abscesses associated with Behçet’s disease are extremely rare. We report a Japanese male diagnosed with an incomplete type of Behçet’s disease who developed multiple aseptic abscesses of the spleen and liver. In 2002, the spleen abscesses were accompanied by paroxysmal oral aphthous ulcers and erythema nodosum. As the patient’s response to antibiotic treatment was inadequate, a splenectomy was performed. Severe inflammatory cell infiltration, largely of polymorphonuclear neutrophils, was observed without evidence of bacterial or fungal growth. Although the patient had no history of ocular symptoms or genital ulcers, a diagnosis of incomplete Behçet’s disease was made according to the Japanese diagnostic criteria because of the presence of paroxysmal arthritis and epididymitis since 2002. In 2005, multiple liver abscesses developed with right hypochondrial pain and seemed to be attributed to Behçet’s disease because the abscesses yielded negative results during a microbiologic investigation and failed to go into remission under antibiotic therapy. Oral prednisone (15 mg/d) was started in May 2006, and the abscesses dramatically disappeared 4 wk after treatment. Although the patient had a relapse of the liver abscesses in association with the tapering of prednisone, the augmentation of prednisone dosage yielded a response. The abscesses of the liver and spleen were strongly suggested to be attributed to Behçet’s disease. Clinician should be aware of the existence of aseptic abscesses as uncommon manifestations of Behçet’s disease.

Increased expression of IL-22 is associated with disease activity in Behcet's disease

OBJECTIVE

Interleukin (IL)-22 has been reported to be involved in the development of autoimmune diseases. This study aimed to analyze the expression and potential role of IL-22 in the pathogenesis of Behcet's disease (BD).

METHODS

The levels of IL-22 in patient sera or supernatants of cultured peripheral blood mononuclear cells (PBMCs) and CD4(+)T cells were detected by enzyme-linked immunosorbent assay (ELISA). Flow cytometry was used to evaluate the frequency of IL-22-producing CD4(+) T cells. IL-22 mRNA from erythema nodosum skin lesions was examined using real time quantitative RT-PCR.

RESULTS

BD patients with active uveitis showed a significantly higher expression of IL-22 in the supernatants of stimulated PBMCs and CD4(+)T cells compared with BD patients without active uveitis and normal controls. An increased frequency of IL-22-producing CD4(+)T cells was also found in BD patients with active uveitis. IL-22 mRNA expression was elevated in erythema nodosum skin lesions. In BD patients, a high IL-22 level in the supernatant of stimulated PBMCs correlated with the presence of retinal vasculitis and erythema nodosum.

CONCLUSIONS

IL-22 was associated with disease activity in BD and correlated with the presence of small vessel inflammation, suggesting that it may be involved in its pathogenesis.

Using methotrexate to treat patients with ENL unresponsive to steroids and clofazimine: a report on 9 patients

Erythema nodosum leprosum (ENL) is a chronic recurrent systemic complication of multi-bacillary leprosy frequently associated with the development of neuritis, iritis, orchitis, arthritis and dactylitis. It is well managed by thalidomide, but thalidomide is not available in Bangladesh. The World Health Organization recommends high doses of clofazimine and prednisolone. About 19% of patients do not respond completely to this regimen or experience relapse when reducing steroid dosage.

OBJECTIVE

We undertook this study to determine whether oral prednisolone combined with methotrexate was an effective and safe treatment regimen for individuals with ENL resistant to clofazimine and prednisolone.

METHODOLOGY

Between September, 2006-June, 2011, we treated nine resistant ENL patients with a combination of prednisolone and methotrexate for 24-36 months with a mean duration of 30 months.

RESULT

We observed improvement leading to persistent remission of ENL in all our patients. Adverse effects were mild weight gain, weight gain with facial swelling, folliculitis and extensive Pityriasis versicolor infection in one patient and crusted scabies in another.

CONCLUSION

A combination of prednisolone and methotrexate was safe and effective in managing ENL not controlled by clofazimine and prednisolone.

Erythema nodosum-like lesions in Behçet's disease: a clinicopathological study of 26 cases

The histopathological features of erythema nodosum-like lesions remain controversial with regard to whether they resemble those of conventional erythema nodosum. We reviewed the clinicopathological features of erythema nodosum-like lesions in 26 patients with Behçet's disease and evaluated the clinical characteristics of Behçet's disease in these patients. The results suggest that: (i) the clinico-pathological features of 27% of the erythema nodosum-like lesions in Behçet's disease are indistinguishable from those of conventional erythema nodosum; (ii) the other 73% of the erythema nodosum-like lesions are histopathologically characterized by the presence of vasculitis (venulitis or phlebitis); (iii) the clinical features of erythema nodosum-like lesions with vasculitis show heterogeneity; (iv) the presence of the erythema nodosum type lesion may be an indicator of the mildness of Behçet's disease; and (v) the presence of severe vasculitis, especially phlebitis, in erythema nodosum-like lesions may be an indicator of the involvement of the gastrointestinal tract in Behçet's disease.

Bacteriological results and leprosy reactions among MB leprosy patients treated with uniform multidrug therapy in China

OBJECTIVES

To investigate the changes of bacteriological index and leprosy reactions among Multi-bacillary (MB) patients treated with uniform multi-drug therapy (UMDT).

METHODS

Newly diagnosed leprosy patients were recruited after taking informed consent in three districts in Guizhou Province and one district in Yunnan Province China during November 2003 to June 2005 and were treated with Uniform Multidrug Therapy. All patients were followed up once a year for 3 years after completion of treatment. All data on bacteriological index (BI) and the frequencies of leprosy reaction were collected and analysed.

RESULTS

A total of 166 patients were recruited for UMDT trial. Among them 114 patients had positive BI smear, and 83 patients had been followed up for 42 months. The mean BI of 83 patients decreased from 2.84 before treatment to 0.33 at the end of 42 months follow-up. At the end of this period, 61 patients (73.5%) had become BI negative. There were 13 (14.6%) patients who had a Type I reaction during 24 months of follow-up. One patient in the study group relapsed 13 months after stopping treatment of the UMDT.

CONCLUSION

There was a significant decrease in the mean BI and 73.5% of patients treated with UMDT became BI negative during 3 years' follow-up. The frequency of Type I reaction seemed a little higher among patients treated with UMDT, but the numbers of patients enrolled were too few to determine statistical significance. Future studies on U-MDT should also study Type I reactions in these patients.

Dermatologic manifestations in inflammatory bowel disease in Tunisia

BACKGROUND

Cutaneous manifestations are the most common extra intestinal manifestations associated with inflammatory bowel disease (IBD).

AIM

To assess the epidemio-clinical profile of skin manifestations in IBD.

METHODS

A prospective and descriptive study was conducted. We have examined skin, mucosa, hair and nails, of all patients with an IBD during one year.

RESULTS

One hundred-ninety-five patients were included. Crohn's disease (CD) was noted in 154 cases (79.8%), ulcerous rectocolitis (UC) in 39 cases (21.2%) and inclassable IBD in 2 cases. Cutaneous manifestations were found in 91% of Crohn's patients and in 92% of UC patients. Granulomatous perianal skin lesions were the main cutaneous manifestations of CD (53%). The most common affected sites were ano-perineal fistulae, perianal and perineal fissures and oedematous and infiltrated perianal and genital plaques. Reactive lesions (Erythema nodosum, Pyoderma gangrenosum, Aphthous stomatitis) were noted in 14 cases. Skin manifestations due to malabsorption were also frequently observed (101 cases: 51.7%).Other dermatoses implicating various mechanisms such as psoriasis, alopecia areata, vitiligo, rosacea, lichen planus, were also noted. Adverse skin manifestations due to treatment (folliculitis, acne, macula-papular rash and DRESS syndrome) were present in 16 cases.

CONCLUSION

Our series is characterized by a high frequency of cutaneous manifestations associated to IBD. A better recognition of these skin manifestations by the physician may improve their management.

Erythema nodosum in kidney transplant recipient: a rare complication of pneumonia treatment

Erythema nodosum (EN) is a cutaneous inflammatory reaction, usually reported in young women, but it is rarely observed among transplant patients. Localization in the lower extremities is typical, mostly involving the anterior surfaces of the legs. Several viral, bacterial, mycotic, and non-infectious etiologies, such as autommune disorders, drugs, inflammatory bowel diseases, sarcoidosis, pregnancy, and malignancies, have been found. We describe the case of a young woman kidney transplant recipient developing bilateral, erythematous, warm nodules localized on the anterior surface of her legs after antibiotic treatment for pneumonia with levofloxacin. Her immunosuppression was sirolimus and mycophenolate mofetil. EN was diagnosed by skin biopsy; microscopic examination showed septal panniculitis with granulomas. As a complete remission of the lesions was obtained in our patient after interruption of levofloxacin therapy, we suspect that levofloxacin was involved in the pathogenesis of EN. In fact, the management of EN is based on the treatment of underlying or associated conditions.

[Etiology of erythema nodosum in rheumatology outpatient clinic]

Erythema nodosum (EN) is a skin lesion presenting with the acute appearance of red nodular eflorescences caused by a reactive immunological process. In most cases EN regresses spontaneously within 3 to 6 weeks and often recurs. This paper is based on a sample of 98 patients from Croatia which were treated in a rheumatologic outpatient clinic by the same internal medicine and rheumatology specialist. Presentation and differences between secondary and idiopathic forms of EN in the Croatian population were analyzed. The results show the final proportion of EN associated with secondary etiology as 47/98. Secondary etiology of EN included mostly infectious diseases (23/98), sarcoidosis (18/98) and IBD (4/98). Comparison of various clinical and laboratory parameters of both idiopathic and secondary EN resulted in a small number of statistically significant differences found (sore throat, recent respiratory infections, ASO titer changes, antibiotics use). The conclusion is that the approach to patients with EN starts by a careful taking of patient history, with an emphasis on recent upper respiratory tract infections and occurrence of diarrhea. A thorough physical examination, basic hematological and biochemical tests, basic inflammatory markers (ESR, CRP), chest X-ray and PPD test are required to determine which patients need further evaluation. A throat swab and/or determination of the titer ofASO on two occasions at intervals of 2-4 weeks should be done. It is important to perform regular patient follow-up. Considering literature substantiated regional differences in the etiology of EN it is recommended that for each population the prevalence of individual causes of EN is determined and the clinical approach accordingly standardized.

[Arthritis, erythema nodosum and genital ulcerations. Behçet disease]

Behcet's disease is a disease of unknown etiology resting in between vasculitis, spondyloarthropathy and autoinflammatory diseases. If his predilection for the population originating from the Silk Road is well known, as are its cutaneous, ocular and vascular manifestations, this case illustrates the non-specificity of those manifestations, the diagnostic difficulties and the importance of routinely assessing for eyes and bowel diseases in this type of patient.

Flexural and extensoral eruptions in dermatologic disease

Dermatologic eruptions can be generalized or localized to specific areas of the body. Eruptions in specific body regions may suggest specific diagnosis. Recognizing such clinical patterns can facilitate the identification of the underlying pathology. In this contribution, we shall discuss those dermatologic lesions that tend to affect the flexure and extensor surfaces.

[A boy with a red swelling of the lower leg]

A 13-year-old boy presented with erythema nodosum on the anterior and lateral side of his lower legs due to enteritis caused by Salmonella enteritidis.

Outbreak of erythema nodosum of unknown cause - New Mexico, November 2007-January 2008

Erythema nodosum (EN) is a form of panniculitis, which has been associated with several infectious and noninfectious etiologies. EN clusters have been associated with outbreaks of Coccidioides immitis, Histoplasma capsulatum, and Yersinia pseudotuberculosis infections. In December 2007, a physician in a rural New Mexico community of approximately 10,000 persons reported to the New Mexico Department of Health (NMDOH) that 13 patients had been diagnosed with EN since mid-November. No EN outbreak had ever been detected in this community, and since 2006, only one diagnosis of EN had been made at the local health-care facility. NMDOH initiated an investigation to confirm the existence of the outbreak, determine the underlying etiology, and implement control measures. This report describes the results of that investigation. Twenty-five EN cases were identified. Seventeen of 20 patients who answered a standard questionnaire reported being at a construction site with crowded and dusty conditions before EN onset. Nine of 15 chest radiographs were abnormal. Serologic test results were interpreted as negative for mycotic agents and inconclusive for Mycoplasma pneumoniae infection. No etiology of the outbreak could be found. During an EN outbreak, timely (acute and convalescent) specimen collection (ideally from case-patients and control subjects to determine baseline seropositivity) and sensitive tests (e.g., polymerase chain reaction [PCR]) are essential to differentiate among possible causes of EN.

Thalidomide: An experience in therapeutic outcome and adverse reactions

BACKGROUND

The US FDA-approved thalidomide for the treatment of chronic recurrent/severe erythema nodosum leprosum. Thalidomide is also useful in many other inflammatory dermatological conditions where patients have exhausted other treatment options.

METHODS

The beneficial and adverse clinical effects of thalidomide were studied in 25 patients suffering from different inflammatory dermatological conditions that were poorly controlled with conventional therapies.

RESULTS

Thalidomide was found to be effective in various inflammatory dermatological diseases other than chronic recurrent erythema nodosum leprosum such as Behçet's disease, disseminated and hypertrophic discoid lupus erythematosus, erosive lichen planus, discoid lupus erythematosus-lichen planus overlap, recurrent aphthous stomatitis and prurigo nodularis. Deep vein thrombosis due to thalidomide occurred in 20% of these patients and appears to be a significant side effect.

CONCLUSION

Thalidomide appears promising in a number of inflammatory dermatological conditions and will probably find new usages in future. The treating physicians need to be wary of the thrombo-embolic complications due to thalidomide especially when glucocorticoids or other chemotherapeutic agents such as doxorubicin, gemcitabine, 5-fluorouracil or dexamethasone-cyclophosphamide pulse therapy are being used concomitantly, and in patients of metastatic renal carcinoma, myelodysplastic syndrome or multiple myeloma receiving thalidomide/chemotherapy. Antiphospholipid or anticardiolipin antibodies appear to be other possible risk factors for this complication.

Erythema Nodosum: An Experience of 10 Years

In this study, we investigated clinical features, aetiology, prospective follow-up results and also factors favouring secondary erythema nodosum (EN) in patients with EN. A total of 50 patients (mean age 38 y) with a diagnosis of EN between 1993 and 2002 in our clinic were included in the study prospectively. A biopsy was performed in 30 of the patients. Patients were considered to have secondary EN when an underlying condition was found, and to have primary (or idiopathic) EN when no such condition was found. For the diagnosis of the underlying diseases, diagnostic criteria and/or diagnostic methods were used. Categorical variables were compared by using chi2 test. The majority of the patients were female (6F/1M) and 54% of cases had a determined aetiology. The foremost aetiology was primary tuberculosis (18%) followed in decreasing order by a poststreptococcal (16%), sarcoidosis (12%), inflammatory bowel diseases (IBD) (4%), Behçet's disease (2%), and pregnancy (2%). All the patients were followed for a mean duration of 7 y. The nodosities relapsed every y in 74% of idiopathic EN patients but in only 1 (Behçet's disease) of the secondary ones. Factors favouring secondary EN were as follows: prolonged fever, cough, sore throat, not relapsing EN, abnormal chest X-ray, leukocytosis, an erythrocyte sedimentation rate of higher than 50 mm/h and a CRP value of higher than 6 times the upper limit of normal. All the patients had bed rest and the majority was given naproxen. The outcomes were usually favourable within 7 d. The patients with an underlying disease were given specific treatment. EN has been associated with numerous diseases. In order to reduce cost and duration of diagnosis, every centre should determine its own most frequent aetiological factors. Factors favouring secondary EN should also be determined. Our study revealed primary tuberculosis, streptococcal pharyngitis, sarcoidosis, IBD, and Behçet's syndrome as the main aetiologies of EN.