Erythema nodosum in children: a study of 27 patients

Erythema nodosum in children: a cohort study from a tertiary pediatric hospital in Italy

Erythema nodosum (EN), although relatively uncommon in the pediatric population, is the most frequent type of panniculitis in children. The present study aimed to report all the cases of children admitted to our tertiary pediatric hospital with the diagnosis of EN to evaluate the epidemiology, clinical manifestations, etiology, treatment, and the course of this disease in the pediatric age. This observational study retrospectively considered all children evaluated to the emergency room (ER) of Meyer Children's University Hospital, Florence, Italy, discharged with a diagnosis of EN over a 12-year period (from January 2009 to December 2021). Clinical and laboratory data were recorded using a standardized report form. Sixty-eight patients with EN were included. The etiologic diagnosis of EN was made in 38 children (55.9%): 29 (42.6%) had infection-related EN (in particular EBV and β-hemolytic streptococcus), 6 (8.8%) had Crohn's disease, 1 celiac disease, 1 Sjogren syndrome, and 1 Hodgkin lymphoma. In 30 patients (45%), no definitive diagnosis was reached, and they were defined as having idiopathic EN. Most of the laboratory tests were nonspecific. No statistical differences were found in the demographic and clinical data, and the main diagnostic laboratory parameters between patients with idiopathic EN versus those with secondary EN.  Conclusion: Since EN can be isolated or the first manifestation of heterogeneous underlying pathologies, some of which can be severe and life-threatening, it is important to recognize it and carry out all the necessary etiological diagnostic investigations to understand its etiology and start the specific treatment. What is Known: • Erythema nodosum (EN) is the most frequent type of panniculitis in children. • It has been associated with a wide spectrum of disorders, such as different types of infection, malignancies, chronic inflammations, and drugs. What is New: • No statistical differences can be found in clinical features as well as laboratory data, between patients with idiopathic EN versus those with secondary EN. • A broad spectrum of investigations and a proper follow-up should be taken into account in order to prevent a delayed or missed secondary EN diagnosis.

Erythema Nodosum in Children: A Narrative Review and a Practical Approach

Erythema nodosum (EN) is the most frequent form of panniculitis in children. We performed a literature review analyzing studies on pediatric EN published from 1990 to February 2022. EN is rare in pediatric age. It can be primary/idiopathic in 23–55% cases, or secondary in 47–77% cases. Secondary EN is related to a wide variety of conditions including infectious diseases, autoimmune disorders, malignancy, drugs, vaccinations, and pregnancy. The diagnosis of EN is clinical, based on the acute appearance of painful and red nodules localized to lower limbs, bilaterally distributed. If EN is diagnosed, basic work-up should include inflammatory markers, serum aminotransferases, lactate dehydrogenase, creatinine, protein electrophoresis, immunoglobulins, testing for streptococcal infection, and a tuberculin skin test. Based on the medical history and associated manifestations, further laboratory and radiological exams should be performed. The prognosis of EN is excellent, with spontaneous resolution in most patients within 2–6 weeks. Treatment, if needed, is addressed to the underlying condition. Despite being a rare manifestation in children, EN can be isolated or the first manifestation of a systemic or infectious condition. EN diagnosis is clinical, and a high index of suspicion is needed to perform investigations for the underlying disorders.

Diagnosis and treatment of dermatologic diseases in inflammatory bowel disease

PURPOSE OF REVIEW

Dermatologic manifestations in patients with inflammatory bowel disease (IBD) are increasingly recognized as related disorders, secondary to specific therapies used to treat IBD, or complications of IBD itself. These dermatologic manifestations can be difficult to manage.

RECENT FINDINGS

We summarize three categories of dermatologic manifestations in this review: extraintestinal cutaneous disorders, paradoxical manifestations to biologic therapies, and other drug-induced cutaneous manifestations. In particular, we provide current data surrounding clinical characteristics, epidemiology, and treatment modalities for individual cutaneous manifestations.

SUMMARY

Many extraintestinal cutaneous manifestations can be managed by optimized treatment of IBD itself, as shared treatment pathways exist. Paradoxical reactions to biologic agents may be driven by the individual biologic therapy. In these instances, if topical therapies or immunomodulators are not effective in treating the paradoxical cutaneous reaction, a change of class may be required. Nonmelanoma and melanoma skin cancers have been linked to specific therapies for IBD (including thiopurines and antitumor necrosis factor alpha agents, respectively). Therefore, optimizing preventive efforts towards skin cancer is warranted. Recognition of these cutaneous disorders by the practicing gastroenterologist is important, as is collaboration with dermatology for management of many cutaneous disorders.

Erythema nodosum

BACKGROUND

Erythema nodosum can be associated with a number of systemic diseases. There is, however, a paucity of information in the pediatric literature on this condition. The purpose of this article is to familiarize pediatricians with the evaluation, diagnosis, and treatment of erythema nodosum.

DATA SOURCES

A PubMed search was completed in Clinical Queries using the key terms "erythema nodosum".

RESULTS

Clinically, erythema nodosum presents with a sudden onset of painful, erythematous, subcutaneous nodules mainly localized to the pretibial areas. Lesions are usually bilateral and symmetrical, ranging from 1 to 5 cm in diameter. Erythema nodosum may be associated with a variety of conditions such as infection, medications, sarcoidosis, pregnancy, inflammatory bowel disease, vaccination, autoimmune disease, malignancy, and miscellaneous causes. The condition is idiopathic in approximately 50% of cases. The diagnosis is mainly clinical with biopsy reserved for atypical cases. To evaluate for the underlying cause, some basic laboratory screening studies are worthwhile in most cases and include a complete blood cell count, erythrocyte sedimentation rate and/or C-reactive protein, throat swab culture, antistreptococcal O titers, and a chest radiograph. Other tests should be individualized, guided by the history and physical examination results. Most cases of erythema nodosum are self-limited and require no treatment. Bed rest and leg elevation are generally recommended to reduce the discomfort. Nonsteroidal anti-inflammatory drugs are the first-line treatment for pain management.

CONCLUSIONS

As erythema nodosum is often a cutaneous manifestation of a systemic disease, a thorough search should be performed to reveal the underlying cause.

Erythema Nodosum and Mycoplasma pneumoniae Infections in Childhood: Further Observations in Two Patients and a Literature Review

Erythema nodosum (EN) is the most frequent panniculitis in childhood and has been associated with various conditions, such as infectious and autoimmune disorders, medications, and malignancies. The author reports on two children affected with EN associated with Mycoplasma pneumoniae infection, which occurred in one patient without pulmonary detection. The available literature on EN and M. pneumoniae infection in childhood is also reviewed.

Childhood erythema nodosum associated with kerion celsi: a case report and review of literature

Erythema nodosum (EN) in association with kerion celsi is a rare condition in children, with only 11 cases having been reported in the English literature. We describe a new case in a 7-year-old boy in whom the disorder had begun 2 months before. He had many inflamed, boggy, suppurative nodules over the left occipitoparietal area of the scalp and, 2 weeks later, developed multiple painful, erythematous subcutaneous nodules of the shins, thighs, and upper limbs. EN was confirmed by histologic examination. Our review of the literature of all cases of EN during kerion showed that it usually occurs at or slightly after the height of infection or after drug introduction. Trichophyton mentagrophytes was involved in the majority of cases, and improvement of EN usually occurs with griseofulvin.

Panniculitis in the newborn: a case report

The authors present a case of panniculitis in a newborn, a rare disease in the neonatal period discussing its causes and differential diagnosis, emphasizing a possible diagnosis of erythema nodosum.

Panniculitis in children

The panniculitides include a group of disorders of varied etiology that manifest as inflamed nodules in the subcutaneous tissue. They are rarely seen in infants and children. The panniculitides of the newborn represent a unique response of the infant's fat to different injuries, and are a specific type of panniculitis that is only seen in neonates and very young infants. These specific panniculitides of children include subcutaneous fat of the newborn, poststeroid panniculitis, sclerema neonatorum, and cold panniculitis. This article reviews in detail the specific types of panniculitis of the newborn and discusses the pediatric aspects of the panniculitis that is often seen in adults.

Erythema Nodosum

Erythema nodosum is the most frequent clinicopathologic variant of panniculitis. The process is a cutaneous reaction that may be associated with a wide variety of disorders, including infections, sarcoidosis, rheumatologic diseases, inflammatory bowel diseases, medications, autoimmune disorders, pregnancy, and malignancies. Erythema nodosum typically manifest by the sudden onset of symmetrical, tender, erythematous, warm nodules and raised plaques usually located on the lower limbs. Often the lesions are bilaterally distributed. At first, the nodules show a bright red color, but within a few days they become livid red or purplish and, finally, they exhibit a yellow or greenish appearance, taking on the look of a deep bruise. Ulceration is never seen, and the nodules heal without atrophy or scarring. Histopathologically, erythema nodosum is the stereotypical example of a mostly septal panniculitis with no vasculitis. The septa of subcutaneous fat are always thickened and variously infiltrated by inflammatory cells that extend to the periseptal areas of the fat lobules. The composition of the inflammatory infiltrate in the septa varies with age of the lesion. In early lesions edema, hemorrhage, and neutrophils are responsible for the septal thickening, whereas fibrosis, periseptal granulation tissue, lymphocytes, and multinucleated giant cells are the main findings in late stage lesions of erythema nodosum. A histopathologic hallmark of erythema nodosum is the presence of the so-called Miescher's radial granulomas, which consist of small, well-defined nodular aggregations of small histiocytes arranged radially around a central cleft of variable shape. Treatment of erythema nodosum should be directed to the underlying associated condition, if identified. Usually, nodules of erythema nodosum regress spontaneously within a few weeks, and bed rest is often sufficient treatment. Aspirin, nonsteroidal antiinflammatory drugs, such as oxyphenbutazone, indomethacin or naproxen, and potassium iodide may be helpful drugs to enhance analgesia and resolution. Systemic corticosteroids are rarely indicated in erythema nodosum and before these drugs are administered an underlying infection should be ruled out.

Panniculitis in childhood and adolescence

BACKGROUND

The purpose of the present paper was to describe the clinical manifestations and treatment of patients with panniculitis.

METHODS

From January 1983 to December 2002, 4294 patients were treated for pediatric rheumatological diseases at Pediatric Rheumatology Unit, University of São Paulo, Brazil. Of these, 35 children and adolescents (0.8%) presented with panniculitis: erythema nodosum (EN) or Weber-Christian disease (WCD). Clinical characteristics, laboratory exams, biopsy of the lesion, treatment and clinical course were studied.

RESULTS

Of the 35 patients, 29 presented with EN and six with WCD, one of these with cytophagic histiocytic panniculitis. Mean age at symptom onset was 85 months (6-204 months) and the mean duration of follow up was 55 months (1-144 months). All the patients presented with inflammatory subcutaneous nodules. The patients with WCD presented with systemic manifestations and cutaneous atrophy. The principal etiologies of EN were streptococcal infection (42%), undetermined (13.5%), pulmonary tuberculosis (10%), and acute rheumatic fever (10%). Biopsy of the nodules indicated septal panniculitis in 14 patients with EN and lobular panniculitis without vasculitis in the patients with WCD, one of which had cytophagic histiocytic panniculitis. There was recurrence in 11 patients (38%) with EN and in all those with WCD. Non-steroidal anti-inflammatory drugs were used in 15 patients with EN and corticosteroids and/or immunosuppressive drugs in the six patients with WCD. Three patients died.

CONCLUSIONS

EN is the most frequent panniculitis, with a benign course and is mainly associated with infections. WCD is a severe disease, with systemic involvement, that proceeds with cutaneous atrophy and requires the use of corticosteroids and or immunosuppressive drugs.

[Erythema nodosum: etiological changes in the last two decades]

OBJECTIVE

To study the etiological factors associated with erythema nodosum in children hospitalized between January 1985 and December 2003.

MATERIAL AND METHODS

We performed a retrospective, descriptive study through review of the medical records of children with a diagnosis of erythema nodosum (MBDS-ICD 9-CM, code 6952). Forty-five patients (27 boys and 18 girls) aged between 10 months and 14 years were studied. The following variables were analyzed: age, sex, associated symptoms, complementary investigations (blood count, erythrocyte sedimentation rate, throat swab, chest x-ray, Mantoux test, ASLO titer, stool culture, serology) and final diagnosis.

RESULTS

The most frequent etiology was tuberculosis (10 patients), followed by Salmonella enteritidis (7 patients), group A beta -hemolytic Streptococcus (3 patients), Salmonella typhimurium (2 patients), Campylobacter jejuni (2 patients), Yersinia enterocolitica (1 patient), infectious mononucleosis caused by Epstein Barr virus (1 patient), cat scratch disease (1 patient), BCG vaccination (1 patient), associated chronic hepatitis B infection (1 patient), and associated amoxicillin treatment (1 patient). Etiology was unknown in 15 patients. The last case of erythema nodosum associated with tuberculous infection dated back to 1991, after which the most frequent etiologic factors associated with erythema nodosum were gastrointestinal pathogens.

CONCLUSIONS

According to our results, the main etiological factor currently associated with erythema nodosum is gastrointestinal infection. Consequently, stool cultures, especially when there are associated gastrointestinal symptoms, are essential.

Panniculitis

The classification of inflammatory disorders of the subcutaneous tissue has mystified dermatologists for decades. Overlapping clinical and histologic features, and a lack of specific treatments have added to the confusion. This article initially classifies the various panniculititides by their primary histopathologic pattern: (1) septal panniculitis without vasculitis, (2) septal panniculitis with vasculitis, (3) lobular panniculitis without vasculitis, and (4) lobular panniculitis with vasculitis. Subsequently, we describe the key clinical findings in the most important forms of panniculitis. We begin with the most common form of panniculitis, erythema nodosum. Indeed, in many patients suspected of having panniculitis, a worthwhile question to consider initially might be, "Is this, or is this not, erythema nodosum?" before engaging in an elaborate (and expensive) exercise in differential diagnosis.

Erythema nodosum induced by kerion celsi of the scalp

A 5-year-old girl presented with a 2-week history of a sharply demarcated, inflammatory, granulomatous lesion on the right side of her scalp. Shortly afterward, painful, subcutaneous nodules developed on her shins and thighs. Trichophyton mentagrophytes was isolated from the scalp lesion and a diagnosis of erythema nodosum induced by kerion of the scalp was made. The patient was started on oral therapy with 18 mg/kg/day griseofulvin, associated with topical crystal violet. Her erythema nodosum regressed in 10 days, while the kerion healed 6 weeks later, leaving residual scarring alopecia. Erythema nodosum represents a reaction pattern to a wide variety of inflammatory stimuli. The interest of this case lies in the unusual association of kerion erythema nodosum, of which only nine cases have been reported in the international literature.

Erythema nodosum in children: a prospective study

BACKGROUND

The studies of series of children with erythema nodosum (EN) are limited and mostly retrospective.

OBJECTIVE

We evaluated the epidemiology, etiology, clinical manifestations, course, and prognosis of EN in children.

METHODS

Thirty-five children with EN (17 boys, 18 girls; mean age, 8.79 years) have been studied. Four excluded children proved, on biopsy, to have leukocytoclastic vasculitis (n = 3) or eosinophilic cellulitis (n = 1).

RESULTS

In 27 of the 35 children (77%), the etiology of EN was established by laboratory investigations. In 25 children the causative factor of EN was an infectious agent (including beta-hemolytic streptococcus [n = 17], and Mycobacterium tuberculosis [n = 2]), whereas in 2 patients, EN was associated with Crohn's disease in one and Hodgkin's disease in the other. In 8 of the 35 children (23%) the etiology of EN remained undetermined. The mean duration of the rash was 11.5 days. Recurrences were noted in only 2 children (1 episode in 1 child and 3 episodes in the other).

CONCLUSION

Currently the most common provoking agent of EN in children in Greece is beta-hemolytic streptococcus. However, Mycobacterium tuberculosis should still be considered as a cause of the disorder. Also, the course of EN is benign and recurrences are exceptional.