Erythema Nodosum: An Experience of 10 Years

[Erythema nodosum]

Erythema nodosum (EN) is the most frequently occurring form of acute panniculitis. It is characterized by painful red to livid raised nodules or bumps that typically occur symmetrically in the shin area. The cause of EN is often a reaction of the immune system to various triggers including infections, inflammatory diseases or medications. In approximately half of the cases no trigger can be identified. After treatment of the underlying pathology EN is typically self-limiting.

A Case of Erythema Nodosum in a 20-Year-Old Female During the Postpartum Period

Erythema nodosum (EN) is the most common form of panniculitis and occurs in about one in 100,000 people. EN typically presents as an eruption of tender, erythematous nodules on the anterior aspect of the legs, although the face, trunk, and arms can also be involved. While the majority of cases are idiopathic, a subset of cases occurs in association with various triggers, including infections, medications, tumors, and autoimmune diseases. Rarely can EN develop in relation to pregnancy, which is thought to provide a physiologic background that favors its development. While pregnancy has been associated with EN in a minority of cases, currently, there is a limited amount of data suggesting that EN can develop in the late postpartum period. Herein, we present a case of a 20-year-old female with a six-week history of painful lesions on her lower extremities. A physical exam revealed multiple tender, erythematous nodules on the anterior aspect of the lower extremities, spanning from the knees to the toes. Laboratory workup showed no other identified triggers of EN in our patient besides pregnancy. Management of EN in our patient involved a low dose, six-day course of prednisone (initial dose of 15 mg/day) and ibuprofen for one week, leading to symptomatic improvement. Our case emphasizes the possibility of EN presenting in the late postpartum period. This case underscores the importance of considering EN in the differential diagnoses for women presenting with compatible lesions postpartum.

Clinico-Laboratory Profile of Tuberculides: An Experience at a Tertiary Care Centre from Chandigarh, India

Background

Tuberculides are characterised by delayed-type of immunologic reactions to Mycobacterium tuberculosis or its products in immuno-competent individuals. We herein describe clinico-epidemiological features and response to treatment in patients with tuberculides from a tertiary care centre from North India.

Methods

This was a retrospective analysis of the clinical records of all the cutaneous tuberculosis (TB) patients (year 2000-2019) enrolled in the TB clinic. The patient records fulfilling the diagnostic criteria of tuberculides were considered for analysis.

Results

A total of 225 patients attended the tuberculosis clinic; out of this, 34 were diagnosed as tuberculides. Out of these 34 cases, 21 were identified as LS, 2 erythema induratum of Bazin, 1 papulonecrotic tuberculide, and 10 erythema nodosum. History of contact to open cases of TB was present in 15/34 (44.1%) patients. History of BCG vaccination was found in 15/34 (44.1%) patients. The focus of underlying TB could be identified in 20/34 (58.8%) patients. Skin biopsy was performed in all patients. In all patients, the diagnosis was confirmed by clinico-pathological correlation, positive TST, and the underlying focus of TB. All patients received 6 months regimen of anti-tubercular therapy with first-line drugs.

Conclusion

In this study, we demonstrated various forms of tuberculides; lichen scrofulosorum was the most common form. We also included erythema nodosum cases also, which responded well to ATT. Observation from our study showed that tuberculides are important cutaneous markers for underlying tuberculosis infection, which helps in early detection of occult tuberculosis and timely management.

Atypical and Typical Presentation of Erythema Nodosum: Clinical Differences in Treatment and Outcome

INTRODUCTION

Erythema nodosum (EN) is the most common form of panniculitis that predominantly affects the shins. While EN in atypical sites has been described by many authors, there are currently only case studies published on this topic. This study aimed to evaluate clinical differences between patients suffering from EN on the shins, compared to patients with EN in atypical locations.

METHODS

We analyzed 105 patients in a retrospective, single-center study at a university hospital in Switzerland. Typical EN was defined as lesions, found only on the lower legs, while atypical EN as lesions on the upper legs, trunk, arms, or face, only or in addition to lesions on the lower legs. The patients were assessed for age, gender, dermatologic history, time until first medical consultation, time to diagnosis, and time until remission. Further, etiology, symptoms, and applied therapies were investigated. Findings were then compared between the typical and atypical EN cohorts.

RESULTS

Overall, we included 70 patients (37.99 ± 15.67 [3-81] years) with EN solely on the shins and 35 patients (41.27 ± 16.85 [9-76] years) with EN on other locations. Interestingly, time until diagnosis was significantly shorter in atypical EN (p = 0.034, 1.14 ± 4.68 vs. 0.46 ± 1.14 months). Time to remission was similar in both groups (3.61 ± 2.73 vs. 3.05 ± 2.86 months, respectively). Sarcoidosis was the only etiologic factor significantly more frequent in atypical EN compared to typical EN (23% vs. 9%, p = 0.042). Besides that, solely subtle differences were seen regarding etiology, gender, age at onset, course of the disease, and symptoms.

CONCLUSIONS

Our study suggests that only minor alterations between both study populations exist. Significant differences were found in time to diagnosis (shorter for atypical EN), as well as in sarcoidosis as an etiologic factor (more frequent in atypical EN). While adalimumab was only prescribed in atypical EN cases, prognosis seems to be similar for typical and atypical EN (similar time to remission, similar amount of reoccurring cases). Due to the limited sample size, however, our study population may have been too small to detect the relevant differences, and bigger studies may be needed.

Erythema nodosum induced by Covid-19 Pfizer-BioNTech mRNA vaccine: A case report and brief literature review

Erythema nodosum (EN), the most common form of panniculitis, is a reactive inflammation of the subcutaneous fat clinically presented with a sudden onset of painful, erythematous, nodular, subcutaneous lesions, typically localized to the pretibial area. EN is commonly caused by numerous infections (especially beta-haemolytic streptococcal infections), autoimmune diseases (sarcoidosis), inflammatory bowel conditions and drugs. EN induced by Covid-19 vaccines is rarely reported. We describe an original clinical observation of a 75-year-old woman who presented with EN after receiving the second dose of BNT162b2, an mRNA vaccine.

Brucella as an unexpected cause of erythema nodosum

Erythema nodosum (EN) is the most common panniculitis which affects individuals from all ages. Etiologically most of the cases are idiopathic EN and infections rank the second. Its clinical presentation is sudden, hot erythematous nodules or plaques in legs, knees or ankles with a diameter ranging between 1 and 5 cm. In the majority of cases, healing is observed within two to eight weeks without any scar tissues. It may occasionally manifest itself as the first symptom of systemic diseases such as sarcoidosis, inflammatory bowel diseases, Behçet’s disease, and other rheumatological conditions. Therefore, EN cases must be carefully examined in terms of their etiologies. Herein, we report an interesting Brucella case presenting as a EN case consulted for rheumatological etiology investigation.

Clinicopathological Characteristics Related to Etiologies of Erythema Nodosum: A 10-Year Retrospective Study

Background

Erythema nodosum (EN) is the most common panniculitis associated with a wide variety of conditions. Updated studies regarding the clinicopathological manifestations related to etiologies of EN and its prognosis are limited.

Objective

We aimed to explore the clinicopathological features in relation to the etiologies of EN and determine characteristics of disease recurrence and its predictive factors.

Methods

A total of 169 patients with biopsy-proven EN or septal panniculitis from January 2008 to September 2018 were retrospectively reviewed. Patients were classified as either idiopathic or secondary EN. Patients’ general information, clinical manifestations, investigations, and recurrence of EN were recorded. The details on histopathological findings were reviewed by a blinded dermatopathologist.

Results

The mean age at diagnosis of EN was 40.6 ± 17.3 years. The majority of patients (85.2%) were female. Idiopathic EN was found in 62.7% of patients. Tuberculosis (23.8%) and drugs (23.8%) were the leading causes of secondary EN. In univariate logistic regression analysis, lesions on upper extremities (p = 0.018), fever (p = 0.003), clinical lymphadenopathy (p < 0.001) favored secondary EN. Histopathologically, the presence of focal peripheral lobular panniculitis with eosinophils was linked to idiopathic EN (p = 0.03). However, multivariable logistic regression analysis failed to demonstrate factors associated with secondary EN. Recurrence was found in 46.6% of patients with no identifiable predictive factors.

Conclusion

Although no clinical risk factors were associated with the etiology of EN, the histopathological presence of eosinophils in focal peripheral lobular panniculitis suggested idiopathic EN.

Erythema Nodosum: A Practical Approach and Diagnostic Algorithm

Erythema nodosum is the most common form of panniculitis and is characterized by tender erythematous nodules mainly in the lower limbs on the pretibial area. The exact cause of erythema nodosum is unknown, although it appears to be a hypersensitivity response to a variety of antigenic stimuli. Although the etiology is mostly idiopathic, ruling out an underlying disease is imperative before diagnosing primary erythema nodosum. Erythema nodosum can be the first sign of a systemic disease that is triggered by a large group of processes, such as infections, inflammatory diseases, neoplasia, and/or drugs. The most common identifiable causes are streptococcal infections, primary tuberculosis, sarcoidosis, Behçet disease, inflammatory bowel disease, drugs, and pregnancy. We propose a diagnostic algorithm to optimize the initial work-up, hence initiating prompt and accurate management of the underlying disease. The algorithm includes an initial assessment of core symptoms, diagnostic work-up, differential diagnosis, and recommended therapies. Several treatment options for the erythema nodosum lesions have been previously reported; nevertheless, these options treat the symptoms, but not the triggering cause. Making an accurate diagnosis will allow the physician to treat the underlying cause and determine an optimal therapeutic strategy.

Erythema Nodosum: A Consequence of Tuberculosis

Erythema nodosum is a form of panniculitis that presents as red lumps most commonly on the shins. It commonly presents due to tuberculosis, streptococcal infections, sarcoidosis, or can be drug related. This report describes the case of a young woman who presented with erythema nodosum and reactive arthritis; this was determined to be a sequelae of tuberculosis. Investigations were ordered as there was a high level of clinical suspicion for an underlying systemic cause for the presenting complaints. The systemic condition was determined to be tuberculosis due to the endemic environment and a positive tuberculin skin test.

Elevated neutrophil to lymphocyte ratio as an indicator of secondary erythema nodosum, a retrospective observational study

Background/aim

Erythema nodosum (EN) is an inflammatory disorder of subcutaneous tissue. Although etiopathogenesis of the disease is unknown, many predisposing factors such as infections, systemic disease, and drugs have been identified. Neutrophil to lymphocyte ratio (NLR) has been shown to be a novel inflammatory marker in many dermatological diseases. The aim of our study is to investigate NLR in EN patients and evaluate its relation to the underlying cause of the disease.

Materials and methods

Between 2014 and 2018, clinical and laboratory data of 395 patients diagnosed with EN and 395 controls were extracted from patient files. EN patients were grouped as idiopathic EN and secondary EN (EN with an identified underlying cause). Clinical and laboratory characteristics of the two groups were compared

Results

NLR was elevated in EN patients compared to controls (median of 2.38 vs. 1.55, P < 0.001). Among EN patients, NLR was also elevated in patients with secondary EN. In multivariate logistic regression model NLR (> 2.11), RDW-CV (> 13.65), and CRP (> 5.5) were identified as risk factors for secondary EN (relative risks were 17.16, 2.69, and 2, respectively).

Conclusion

Elevated NLR (> 2.11) may be used as a parameter to discriminate secondary EN from idiopathic EN.

Drug Hypersensitivity Reactions Documented in Electronic Health Records within a Large Health System

BACKGROUND

Hypersensitivity reactions (HSRs) are immunologic responses to drugs. Identification of HSRs documented in the electronic health record (EHR) is important for patient safety.

OBJECTIVE

To examine HSR epidemiology using longitudinal EHR data from a large United States health care system.

METHODS

Patient demographic information and drug allergy data were obtained from the Partners Enterprise-wide Allergy Repository for 2 large tertiary care hospitals from 2000 to 2013. Drug-induced HSRs were categorized into immediate and delayed HSRs based on typical phenotypes. Causative drugs and drug groups were assessed. The prevalence of HSRs was determined, and sex and racial differences were analyzed.

RESULTS

Among 2.7 million patients, 377,474 (13.8%) reported drug-induced HSRs, of whom 70.3% were female and 77.5% were white. A total of 580,456 HSRs were reported, of which 53.1% were immediate reaction phenotypes. Common immediate HSRs included hives (48.8%), itching (15.0%), and angioedema (14.1%). Delayed HSR phenotypes (46.9%) were largely rash (99.0%). Penicillins were associated with the most immediate (33.0%) and delayed (39.0%) HSRs. Although most HSRs were more prevalent in females and white patients, notable differences were identified for certain rare HSRs including acute interstitial nephritis, which appeared more commonly in males (0.02% vs 0.01%, P < .001). Asian patients had more fixed drug eruptions (0.007% vs 0.002%, P = .021) and severe cutaneous adverse reactions (0.05% vs 0.04%, P < .001).

CONCLUSIONS

Drug HSRs were reported in 13.8% of patients. Almost one-half of reported immediate HSR phenotypes were hives, and almost all reported delayed HSR phenotypes were rash. HSRs largely affected female and white patients, but differences were identified for specific rare HSRs.

Successful treatment of erythema induratum with topical application of antituberculous drugs: A case report

RATIONALE

Erythema induratum, a chronic recurrent lobular panniculitis with vasculitis, is strongly associated with Mycobacterium tuberculosis infection. The recommended drugs include isoniazid, rifampicin, and pyrazinamide, which are typically administered in combination (orally or intravenously). Till date, there are no reports about topical application of anti-tuberculous (anti-TB) drugs for treatment of erythema induratum.

PATIENT CONCERNS

Herein, we present the case of a 73-year-old woman with recurrent ulceration, scarring and obvious pain in her lower legs.

DIAGNOSES

She was diagnosed of erythema induratum.

INTERVENTIONS

Topical anti-TB treatment (3.75% isoniazid twice a day) was necessitated by the development of severe gastrointestinal upset and significant reduction in platelets after oral treatment with isoniazid and rifampicin.

OUTCOMES

The skin lesions showed improvement at one month and remitted mostly at two months. After 6 months, the skin lesions have subsided and no obvious side effects were observed.

LESSONS

Our experience may help expand the therapeutic regimens for cutaneous tuberculosis, and provide physicians with alternative options for management of tuberculosis.

Environmental sensitivity as a trigger of erythema nodosum and perimenopausal symptoms

A 45-year-old woman presented to the University of Arizona Integrative Medicine Clinic for advice on managing recurrent erythema nodosum (EN), along with recent onset perimenopausal symptoms. Her painful EN flares had occurred two to six times per year over the past 14 years, yet had attenuated over the past 5 years until recently, and she presented with bilateral EN lesions on the shins. An environmental exposure history revealed that a new plastic-containing water pot had been introduced at her office just prior to her latest EN flare. She was told to eliminate environmental exposure to plastics, including this new coffee pot. She eliminated exposures to heated plastics, and replaced her coffee pot with a stainless steel one. Within weeks of removing these potential environmental triggers, her EN lesions cleared completely, and her menses normalised. An unintentional re-exposure to plastics 2 months later resulted in an EN recurrence within 2 hours.

Unilateral Erythema Nodosum following Norethindrone Acetate, Ethinyl Estradiol, and Ferrous Fumarate Combination Therapy

Erythema nodosum is a septal panniculitis that typically presents as symmetric, tender nodules on the anterior aspects of bilateral lower extremities. Nearly half of cases are due to secondary causes, with oral contraceptive pills being the leading pharmaceutical cause. However, to our knowledge, there has yet to be a published association with norethindrone acetate, ethinyl estradiol, and ferrous fumarate. We report our experience with a 30-year-old woman who developed unilateral tender nodules within a month of starting 1 mg norethindrone acetate and 20 mcg ethinyl estradiol daily. Of note, she had previously taken oral contraceptives with the same estrogen agent but different progesterone, without problems. We conclude that systemically triggered erythema nodosum can present with lesions localized to one extremity. When a patient presents with tender, firm nodules, clinicians should consider the possibility of erythema nodosum and its triggers, such as oral contraceptives. Additionally, should a patient on hormonal therapy develop erythema nodosum, changing the progesterone agent may allow the patient to continue similar therapy without developing symptoms.

Role of nidi of infection in various skin diseases

Reviewed scientific publications that define the location of foci of chronic infections in dermatology. Indicated by the currently existing problematic issues and their solutions.

Clinical presentations of Behçet's disease among Nigerians: a 4-year prospective study

BACKGROUND

Behçet's disease (BD) is a chronic, multisystem, inflammatory pan-vasculitis of unknown etiology, with heterogeneous presentations in different parts of the world. It commonly involves the mucosae, skin, joints, eyes, and central nervous system. Behçet's disease is considered to represent an autoimmune reaction triggered by a yet to be identified infectious agent in a genetically predisposed person. It most commonly affects persons of Mediterranean or Far Eastern origin and is considered rare among Black Africans.

OBJECTIVES

This study was conducted to document clinical presentations of BD in Nigerians.

METHODS

A prospective study of the clinical and laboratory parameters of patients who attended dermatology and rheumatology clinics between 2007 and 2011 was carried out.

RESULTS

Fifteen patients (nine males, six females) were diagnosed with BD at a mean age of 33 years. The mean age of onset of disease was 27 years. Oral ulceration was present in 100% of subjects and was the most frequent onset lesion, followed by genital ulceration in 93%. Skin, joint, vascular, gastrointestinal, and central nervous system (CNS) lesions occurred in 87, 80, 33, 20, and 13% of patients, respectively. Pathergy tests were positive in 38% of patients. Psychomorbidity was present in 60%. Remission was achieved with corticosteroids, nonsteroidal anti-inflammatory drugs, and disease-modifying anti-rheumatic drugs. Mortality was zero, but 27% of patients were disabled by blindness and 7% by CNS involvement.

CONCLUSIONS

This is the first report on BD in a sample of Nigerians. The clinical phenotype of BD follows the Middle Eastern pattern. The small number of patients may reflect the rarity of BD in Nigerians or the poor ascertainment of BD by relevant clinicians.

Cutaneous manifestations in patients with inflammatory bowel diseases: pathophysiology, clinical features, and therapy

The skin is one of the most common extraintestinal organ system affected in patients with inflammatory bowel disease (IBD), including both Crohn's disease and ulcerative colitis. The skin manifestations associated with IBD are polymorphic and can be classified into 4 categories according to their pathophysiology: (1) specific, (2) reactive, (3) associated, and (4) induced by IBD treatment. Cutaneous manifestations are regarded as specific if they share with IBD the same granulomatous histopathological pattern: perianal or metastatic Crohn's disease (commonly presenting with abscesses, fistulas or hidradenitis suppurativa-like features) is the prototype of this setting. Reactive cutaneous manifestations are different from IBD in the histopathology but have close physiopathological links: pyoderma gangrenosum, a neutrophil-mediated autoinflammatory skin disease typically manifesting as painful ulcers, is the paradigm of this group. Among the cutaneous diseases associated with IBD, the most commonly seen are erythema nodosum, a form of panniculitis most commonly involving bilateral pretibial areas, and psoriasis, a T helper 1/T helper 17-mediated erythematous squamous inflammatory disease. Finally, the number of cutaneous adverse reactions because of IBD therapies is progressively increasing. The most frequent drug-induced cutaneous manifestations are psoriasis-like, eczema-like, and lichenoid eruptions, as well as cutaneous lupus erythematosus for biologics, and nonmelanoma skin cancer, mainly basal cell and squamous cell carcinomas for thiopurines.

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.

Mycobacterium tuberculosis infection is associated with the development of erythema nodosum and nodular vasculitis

Background

Mycobacterium tuberculosis (MTB) infection has been suggested to contribute to the pathogenesis of erythema nodosum (EN) and nodular vasculitis (NV), the classic forms of panniculitis. However, there is little evidence to demonstrate the presence of MTB in the skin lesions. This study is aimed at evaluating the association between MTB infection and the development of EN and NV in a Chinese population.

Methods

A total of 107 patients (36 EN, 27 NV, and 44 others) with vasculitis and 40 control cases with other skin diseases were recruited and their skin lesion samples were subjected to real time polymerase chain reaction (PCR) analysis of the IS6110 and mpt64 gene fragments of MTB. Their blood mononuclear cells were tested for MTB antigen-specific IFN-γ responses by QuantiFERON®-TB Gold In-Tube (IT) assays.

Results

PCR analysis revealed that 7/23 (30.4%) and 7/18 (38.9%) of the EN and NV samples were positive for the IS6110 DNA, respectively, which were significantly higher than 3/34 (8.8%) of other vasculitis (OV) and 3/40 (7.5%) of the control samples (p<0.05). The nested Real-Time PCR assay indicated that 6/7 (86%) of the IS6110-positive EN samples, all of the IS6110-positive NV and control samples, but only 1/3 of the IS6110-positive OV samples, were positive for the mpt64 gene. Similarly, 19/32 (59.4%) of the EN patients, 20/26 (76.9%) of the NV patients, and 17/36 (47.2%) of the OV patients were positive for MTB antigen-specific IFN-γ responses, which were significantly higher than 6/40 (15%) of the controls (p<0.05).

Conclusion

Our data strongly suggest that MTB infection and active TB are associated with the development of NV and EN in Chinese.

Characteristics of fever, etiologic factors, antibiotic use and prognosis in febrile dermatology inpatients

BACKGROUND

Generally, fever is observed in >30% of hospitalized patients. However, little is known about fever in dermatology inpatients.

OBJECTIVES

The aim of this study was to investigate and document the incidence, characteristics, and etiologic factors of fever in febrile dermatology inpatients and to describe the practice of antibiotic use and prognosis in the same group.

METHODS

The medical records for 928 inpatients were retrospectively analyzed.

RESULTS

The incidence of fever was found to be 16.2%. Mean length of hospital stay was found to be longer in febrile patients. Of the 176 febrile episodes, 79 (44.9%) occurred in patients without infections, 43 (24.4%) in patients with community-acquired infections, 25 (14.2%) in patients with healthcare-associated infections, 18 (10.2%) in patients classified with fever of non-infectious/infectious causes, and 11 (6.3%) in a group for whom the etiologic factors of fever were undetermined. Antibiotic treatment was started in 36.2% of febrile inpatients. The overall mortality rate was 0.6%.

CONCLUSIONS

This is the first study to investigate febrile episodes in dermatology inpatients. Fever is a frequently encountered symptom in dermatology inpatients. Febrile episodes resulted from mostly non-infectious entities, mainly consisting of inflammatory dermatologic disorders. Antibiotics were ordered in a higher percentage of patients in the febrile group. Dermatologists started prophylactic or empiric antibiotic therapy in febrile patients with non-infectious or inflammatory diagnoses on the assumption that these patients had an increased risk for infection as a result of impaired skin integrity and use of immunosuppressive drug therapy. The overall mortality rate was very low in the study group of dermatology inpatients.

Simultaneous occurrence of erythema nodosum in monozygotic twin sisters

Erythema nodosum (EN) is the most frequent clinicopathologic variant of panniculitis with painful red or violaceous nodules on the anterior surfaces of the legs. The condition is a cutaneous reaction that might be associated with a wide variety of disorders or might be caused by medications that produce painful nodules on the shins, and less commonly on the thighs and forearms. In this paper, we describe, for the first time in the world, erythema nodosum as the simultaneous presenting complaint of monozygotic twin sisters after streptococcal pharyngitis. This paper might support the effect of heredity in the occurrence of erythema nodosum.

Skin manifestations of inflammatory bowel disease

Inflammatory bowel disease (IBD) is a disease that affects the intestinal tract via an inflammatory process. Patients who suffer from IBD often have diseases that affect multiple other organ systems as well. These are called extraintestinal manifestations and can be just as, if not more debilitating than the intestinal inflammation itself. The skin is one of the most commonly affected organ systems in patients who suffer from IBD. The scientific literature suggests that a disturbance of the equilibrium between host defense and tolerance, and the subsequent over-activity of certain immune pathways are responsible for the cutaneous disorders seen so frequently in IBD patients. The purpose of this review article is to give an overview of the types of skin diseases that are typically seen with IBD and their respective pathogenesis, proposed mechanisms, and treatments. These cutaneous disorders can manifest as metastatic lesions, reactive processes to the intestinal inflammation, complications of IBD itself, or side effects from IBD treatments; these can be associated with IBD via genetic linkage, common autoimmune processes, or other mechanisms that will be discussed in this article. Ultimately, it is important for healthcare providers to understand that skin manifestations should always be checked and evaluated for in patients with IBD. Furthermore, skin disorders can predate gastrointestinal symptoms and thus may serve as important clinical indicators leading physicians to earlier diagnosis of IBD.

Cellulitis: diagnosis and management

Cellulitis is an acute infection of the dermal and subcutaneous layers of the skin, often occurring after a local skin trauma. It is a common diagnosis in both inpatient and outpatient dermatology, as well as in the primary care setting. Cellulitis classically presents with erythema, swelling, warmth, and tenderness over the affected area. There are many other dermatologic diseases, which can present with similar findings, highlighting the need to consider a broad differential diagnosis. Some of the most common mimics of cellulitis include venous stasis dermatitis, contact dermatitis, deep vein thrombosis, and panniculitis. History, local characteristics of the affected area, systemic signs, laboratory tests, and, in some cases, skin biopsy can be helpful in confirming the correct diagnosis. Most patients can be treated as an outpatient with oral antibiotics, with dicloxacillin or cephalexin being the oral therapy of choice when methicillin-resistant Staphylococcus aureus is not a concern.

Primary inoculation skin tuberculosis by accidental needle stick

A 42-year-old female laboratory worker presented with a left index finger skin lesion after an accidental prick while handling samples of a cultural exam of Mycobacterium tuberculosis. Surgical excision was performed and pathology analysis revealed a dermic chronic inflammatory process with no granulomas. Later, a non-painful lymphadenopathy appeared in the left axilla as well as brownish indurated skin lesions in the lower limbs consistent with erythema nodosum. Fine needle aspiration biopsy of the lymph node revealed epithelioid granulomas, Langhans' multinucleated giant cells and the presence of acid-fast bacilli. Standard tuberculosis treatment resulted in regression of lesions and no relapses occurred in the 2-year follow-up period.

[Chronic inflammatory and autoimmune mediated dermatoses during pregnancy. Course and prognosis for mother and child]

Chronic inflammatory dermatoses during pregnancy can take varying courses in mother and child. The dominant Th2-response characteristic for pregnancy may explain why atopic eczema or lupus erythematosus may deteriorate while psoriasis vulgaris may improve. In contrast, impetigo herpetiformis frequently shows a severe course. Lupus erythematosus and other autoantibody-triggered dermatoses like pemphigus vulgaris pose an increased risk for the child because of placental transfer of autoantibodies with specific skin changes or systemic manifestations of the disease as well as placental insufficiency, growth retardation and premature birth. Such risks are not associated with linear IgA dermatosis. A severe pityriasis rosea during the first 20 weeks of pregnancy may lead to an increased risk of abortion or premature delivery. Early diagnosis and individually adjusted therapy of skin diseases is mandatory to avoid any risk for mother or child.

An Update on C-reactive Protein for Intensivists

This review aims to summarise the physiology of C-reactive protein (CRP), its possible roles and limitations as an inflammatory and infective marker in intensive care medicine, and also the emerging roles of CRP in the pathogenesis of cardiovascular and autoimmune diseases. Observational and animal studies on uses of CRP were retrieved from the PubMed database without any language restrictions. Quantitative data were not pooled because of the heterogeneity of patient characteristics and disparate ways in which CRP was studied. Serum CRP concentrations are determined by the synthetic rate of its production in the liver regulated predominantly by interleukin-6. It has a half-life of 19 hours and is relatively slow in its onset and offset in response to an acute inflammatory process when compared to procalcitonin. It has some favourable properties and limitations as an inflammatory marker. An elevated CRP concentration is not specific to infections and the absolute CRP concentrations cannot be used to differentiate between bacterial, fungal and severe viral infections. The dynamic response of CRP to therapy that aims to modify the underlying inflammatory process and the clinical context of a patient are of pivotal importance when CRP concentrations are interpreted. CRP is found to be a significant partaker and prognostic factor in a wide range of cardiovascular and chronic diseases. In summary, CRP concentration is an important prognostic factor of many acute and chronic diseases. Serial CRP measurements may be useful to reflect a patient's response to therapy that aims to modify the underlying inflammatory process.

Skin manifestations of inflammatory bowel disease

Ulcerative colitis (UC) is an inflammatory disorder of the colon that is associated with several extraintestinal manifestations in multiple organs. Several mucous membrane and skin disorders occur in patients with UC. These disorders are not unique to UC and often occur secondary to other causes or in the absence of an apparent cause. One or more such disorders may occur together in association with UC. Mucous membrane and skin disorders may antedate, occur with, or postdate the onset of UC. The dermatologist plays an important role in suspecting the diagnosis of UC that presents with associated mucous membrane or skin disorders. This review covers the clinical presentation, differential diagnosis, workup, and management of selected mucocutaneous manifestations in UC.

Clinical manifestations associated with high titer of anti-streptolysin O in Behcet's disease

To evaluate the association of chronic infection with clinical features of Behcet's disease (BD), we studied epidemiological and clinical features of 149 patients with only aphthous ulcer and 294 patients with BD. The incidence of chronic infection history was compared between both groups with age- and sex-matching and clinical manifestations of BD associated with high anti-streptolysin O (ASO) titer were investigated. BD patients had more common history of tonsillitis and dental caries than aphthous ulcer patients (P = 0.002 and P = 0.043, respectively). BD patients with persistently high anti-streptolysin O titers had more frequent history of tonsillitis (P = 0.001, odds ratio [OR] = 2.99, 95% confidence interval [CI] 1.53-5.82) and erythema nodosum (EN)-like lesions (P = 0.001, OR = 3.02, 95% CI 1.54-5.93) and fewer history of genital ulcer (P = 0.027, OR = 0.21, 95% CI 0.05-0.84) than BD patients with normal anti-streptolysin O titer. Our results suggest persistently high ASO titers in BD patients could indicate that streptococcal infections such as tonsillitis are related to BD symptoms such as EN-like lesions. In these patients, ASO titer can be used in the evaluation of BD disease activity and antibiotic treatments might be effective to control the symptoms of BD.

Cabergoline-associated erythema nodosum

OBJECTIVE

To report a case of erythema nodosum (EN) and related inflammatory arthropathy in a patient on cabergoline therapy for a microprolactinoma.

CASE SUMMARY

A 25-year-old white female, who had been receiving cabergoline 0.5 mg orally once per week for the preceding 2 months for a microprolactinoma, developed classic skin lesions of EN (proved by histology) and an associated acute inflammatory arthropathy of her left ankle joint in the absence of any other identifiable causes of EN. She improved substantially (skin lesions of EN and inflammatory arthropathy disappeared) after cessation of cabergoline therapy. Rechallenge with cabergoline in a lower dose of 0.25 mg orally once per week led to a milder recurrence of EN lesions that once again disappeared after withdrawal of the drug. She had not had a recurrence at a 3 month follow-up visit.

DISCUSSION

Although possible autoimmune adverse effects (pleuropulmonary and cardiac) have been reported with the use of cabergoline, to the best of our knowledge, this is the first case report of EN (panniculitis) associated with cabergoline therapy. Causality assessment using the Naranjo probability scale revealed that the adverse drug event was probable.

CONCLUSIONS

Cabergoline was probably associated with EN (panniculitis) and the related arthritis in a patient being treated for a microprolactinoma. Panniculitis, like EN, needs to be considered a possible but reversible adverse effect of cabergoline therapy for microprolactinoma of the pituitary gland.

Erythema nodosum: clinicopathologic correlations and their use in differential diagnosis

PURPOSE

Typically, a diagnosis of erythema nodosum (EN) is based on clinical features. However, other diseases manifest with inflammatory nodules of the lower limbs in addition to EN, such as the EN-like lesions of Behcet's disease (BD). The purpose of this retrospective study was to investigate the frequency of histologically proven EN among diseases diagnosed clinically as EN, to determine underlying causes of EN, and to compare clinical and histologic features between EN and other diseases.

PATIENTS AND METHODS

We selected 99 patients diagnosed clinically with EN and performed skin biopsies. All pathologic slides were evaluated and diagnosed; and after histologic diagnoses were made we reviewed the patients' medical records.

RESULTS

Among the 99 patients diagnosed clinically with EN, 47 were biopsy-verified EN. The EN-like lesions of BD and nodular vasculitis were both in the primary differential diagnosis of EN. No definite difference in clinical features exists among these three diseases. Histologically, EN demonstrated septal panniculitis in the majority of patients. Lobular panniculitis was frequently observed in NV, and mixed or mostly lobular panniculitis was observed in the EN-like lesion. Vasculitis was rarely observed in EN; however lymphocytic vasculitis was observed frequently in EN-like lesions and neutrophilic vasculitis was observed in NV. The frequency of granulomatous inflammation was highest in NV. Some cases of patients with typical BD demonstrated classic EN lesions.

CONCLUSION

It was extremely difficult to clinically differentiate EN from EN-like lesions or NV. We feel skin biopsy is mandatory for the diagnosis of lower extremity erythematous nodular lesions.

Cutaneous manifestations of tuberculosis

Cutaneous involvement is a rare manifestation of tuberculosis (TB). The correct diagnosis is often significantly delayed because cutaneous TB is not routinely considered in the differential diagnosis or because investigations fail to reveal the presence of Mycobacterium tuberculosis. The clinical features of cutaneous TB are diverse, and result from exogenous and endogenous spread of M. tuberculosis and from immune-mediated mechanisms. The recognition of cutaneous TB is important, as the diagnosis is frequently overlooked resulting in delayed treatment.

Erythema nodosum and lung ailments at the clinic for dermatological and venereal diseases in Sarajevo from 1989 to 2005

In 15 years period (1989 - 2004) we have treated at our Clinic a total of 101 patients diagnosed with erythema nodosum which makes 2.9% of the total number of patients treated in this period. In order to explore correlation between dermatological and lung diseases we applied statistical analysis with respect to number, sex, age and irregularities occurring on the skin surface. Female patients dominated with 96 of them (95.6%) in the group, while only five patients were male (4.3%). This makes 22 : 1 scale in favor of female patients, as opposed to usual 5:1 ratio. Similar predominance (86%) was found in the study conducted by Mert and Gurkan (1.2). Average age of the patients was 41.6 years, which is slightly higher than the average of 18 and 34. The youngest patient was 17 and oldest 77.