The Distinct Pattern of Granulomatous Lobular Mastitis with Erythema Nodosum: More Severe Conditions and Extensive Lesions

PURPOSE

Granulomatous lobular mastitis (GLM) is a benign inflammatory disease of the mammary gland with unknown etiology. Erythema nodosum (EN) is a rare, extramammary symptom of GLM. The purpose of this article was to investigate the clinical features of EN associated with GLM.

METHODS

We recruited 102 GLM patients diagnosed between December 2018 and December 2021 at Renmin Hospital of Wuhan University. The clinical characteristics and laboratory indices of the EN group (n = 12) and the non-EN group (n = 90) were compared.

RESULTS

The proportion of GLM patients with lesions involving ≥2 quadrants and high peripheral white blood cell count, absolute neutrophil count and neutrophil-to-lymphocyte ratio (NLR) was larger in the EN group than in the non-EN group (p = 0.002, 0.025, 0.014, 0.002, respectively). The duration of EN was longer in GLM patients with EN than in GLM patients without EN (p = 0.005). GLM patients with EN had more abscesses and sinus tracts than those without EN (p = 0.003, 0.038). Lesions involving ≥2 quadrants and the NLR were positively associated with the occurrence of EN (R = 0.304, 0.0302, p = 0.002, 0.002). Receiver operating characteristic curve analysis revealed that the area under the curve of the NLR was 0.770. When NLR > 5.73, the sensitivity and specificity of predicting EN were 66.67% and 87.78%, respectively.

CONCLUSION

Our findings suggest that GLM concomitant with EN suggests the presence of a more severe condition and extensive lesions.

Erythema Nodosum Induced by the Pfizer- BioNTech Vaccine

A 42-year-old man presented with a painful nodular dermatitis with 38.5°C fever and joint pain, which started overnight. The patient had taken the first dose of Pfizer-BioNTech (Comirnaty, INN-COVID-19 mRNA) vaccine 8 days ago. He denied any kind of recent infections, inflammatory conditions, malignancies, or drugs administration.

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 as key manifestation of histoplasmosis case

Histoplasmosis is a systemic infection caused by the fungus, Histoplasma capsulatum Infection of H. capsulatum frequently occurs by inhaling the spores of the fungus, which is found in bat and bird droppings, or soil enriched with their excrement. If not detected and treated, histoplasmosis can develop late, severe complications such as mediastinal fibrosis, or even develop into a disseminated infection. However, histoplasmosis infections are often asymptomatic, making its detection more difficult. Further, only 6% of histoplasmosis cases will present with erythema nodosum, with most cases associated with female patients. This case presents a woman in her 50s with a pertinent history of fibromyalgia and hypothyroidism secondary to Hashimoto's who initially sought medical care for painful nodules on her legs and was eventually diagnosed with histoplasmosis. This report clearly demonstrates the importance of maintaining a broad differential when working up inflammatory manifestations, such as erythema nodosum.

Predictive Factors of Severe Behçet's disease: A Longitudinal, Prospective Cohort Followed Between 1981-2020

INTRODUCTION

Behçet's disease (BD) is a systemic vasculitis of unknown cause. The spectrum of the disease ranges from mucocutaneous manifestations to other organ diseases with relevant morbidity. Associations between disease severity and male sex, earlier age at onset, and the presence of erythema nodosum have been described.

OBJECTIVES

To evaluate clinical factors associated with manifestations of severe disease in a single-center cohort.

METHODS

A longitudinal, prospective, unicentric cohort study with patients followed in a specialized outpatient clinic between 1981 and 2020. Severe BD was defined as a Krause total clinical severity score >4 points.

RESULTS

We included 243 patients, of whom 31% were male, with an average follow-up time of 14.6 years. Regarding organ manifestations, all patients had mucous manifestations (N=243, 100%), 133 (55%) skin, 104 (43%) joint, 71 (29%) ocular, 48 (20%) vascular, 47 (19%) neurological, 22 (9%) gastrointestinal and 1 (0.4%) cardiac involvement by BD. One hundred fifty-six (64%) patients were classified as having severe BD. Severe BD was more frequent in men (OR=2.004, p=0.024), increasing with age (OR=1.021 per year, p=0.037), in the presence of skin manifestations (OR=4.711, p<0.001), specifically erythema nodosum (OR=8.381, p<0.001), and pseudofolliculitis (OR=2.910, p<0.001). In the multivariate model, variables independently associated with severe BD were male gender (Adjusted OR=1.961, p=0.047), erythema nodosum (Adjusted OR=8.561, p<0.001) and pseudofolliculitis (Adjusted OR=2.372, p=0.007).

DISCUSSION

Male gender, erythema nodosum, and pseudofolliculitis were independently associated with severe BD forms and therefore should serve as warning signs to the clinician.

A United States expert consensus to standardise definitions, follow-up, and treatment targets for extra-intestinal manifestations in inflammatory bowel disease

BACKGROUND AND AIMS

Extra-intestinal manifestations (EIMs) are a common complication of inflammatory bowel diseases (IBD), affecting up to half of the patients. Despite their high prevalence, information on standardised definitions, diagnostic strategies, and treatment targets is limited.

METHODS

As a starting point for a national EIM study network, an interdisciplinary expert panel of 12 gastroenterologists, 4 rheumatologists, 3 ophthalmologists, 6 dermatologists, and 4 patient representatives was assembled. Modified Delphi consensus methodology was used. Fifty-four candidate items were derived from the literature review and expert opinion focusing on five major EIMs (erythema nodosum, pyoderma gangrenosum, uveitis, peripheral arthritis, and axial arthritis) were rated in three voting rounds.

RESULTS

For use in a clinical practice setting and as part of the creation of a prospective registry of patients with EIMs, the panel developed definitions for erythema nodosum, pyoderma gangrenosum, uveitis, peripheral arthritis, and axial arthritis; identified the appropriate and optimal subspecialists to diagnose and manage each; provided methods to monitor disease course; offered guidance regarding monitoring intervals; and defined resolution and recurrence.

CONCLUSIONS

Consensus criteria for appropriate and optimal means of diagnosing and monitoring five EIMs have been developed as a starting point to inform clinical practice and future trial design. Key findings include straightforward diagnostic criteria, guidance regarding who can appropriately and optimally diagnose each, and monitoring options that include patient and physician-reported outcomes. These findings will be used in a national multicenter study network to optimise the management of EIMs.

Inflammatory Bowel Disease: Its Effects on Physical Activity, Sports Participation, and Athletes

ABSTRACT

This article discusses the "bidirectional" relationship between inflammatory bowel disease (IBD) and physical activity. Intestinal symptoms and extraintestinal manifestations of IBD negatively impact a patient's ability to participate in sports. IBD also impacts athletic performance via its effects on muscle mass, muscle function, bone density, and fatigue. Surveys of IBD patients consistently show that IBD interferes with athletic participation. While IBD negatively affects physical activity, there is growing evidence that physical activity can be beneficial for IBD patients. Prospective studies have revealed that structured physical activities may positively influence inflammatory markers, disease activity, muscle strength, bone density, fatigue, stress, anxiety, and quality of life. This suggests that physical activity may be a simple and safe adjuvant therapy for IBD patients. Future studies assessing the optimal activity regimen are warranted. Finally, a cohort of professional athletes with IBD are described for the first time - football players in the National Football League.

Persistent Infection Versus Type 2 Immunological Reaction in Lepromatous Leprosy

The distinction between persistent infection and immunologic reactions in leprosy is often difficult but critically important since their management is different. We present the case of a 51-year-old Vietnamese female who presented in 2015 with areas of erythema and skin infiltration on face and chest, as well as edema on her hands and feet. Skin biopsy was consistent with lepromatous leprosy. She was treated with rifampin, clarithromycin, and levofloxacin for 2 years. Her lower extremity edema was attributed to type 2 immunological reaction for which she was started on prednisone and methotrexate, but she was lost to follow-up for 19 months. She presented with new skin lesions and pain on her extremities. New biopsies revealed an intense neutrophilic infiltrate in the dermis and acid-fast bacilli focally within cutaneous nerve twigs. As compared with the initial biopsy, the inflammatory infiltrates were diminished and the bacilli had a degenerating appearance. These findings were consistent with type 2 immunological reaction. The patient was treated with thalidomide with improvement in the appearance of the skin lesions. A follow-up biopsy showed lack of neutrophilic infiltrates and decreased number of bacilli. This case illustrates the importance of differentiating between persistent infection and immunologic reactions in leprosy. Clinicians should be aware of these complications. A high index of suspicion and accurate interpretation of skin biopsy results are essential for appropriate diagnosis.

Etiological factors and histopathological features in erythema nodosum: a 6-year retrospective cross-sectional study

INTRODUCTION

Erythema nodosum (EN) is the most common type of panniculitis. The most frequent etiological factors are streptococcal pharyngitis, sarcoidosis, Behçet's disease, and tuberculosis. Our objective was to identify the etiological factors and to evaluate the patients' clinical, laboratory, and histopathological findings.

METHODS

Eighty-eight patients diagnosed with EN at our clinic between 2013 and 2019 were evaluated retrospectively. Sixty-five patients were evaluated histopathologically.

RESULTS

The patients' ages ranged between 17 and 76 (mean age: 41.91 ± 13.07 years). EN was 7.8 times more frequent in women. Patients presenting with idiopathic EN were significantly older than secondary cases (p < 0.05). Sixty-one patients (69.3%) had an underlying disease (secondary EN). The most common etiological factors were upper respiratory tract infections (n = 26), followed by Behçet's disease (n = 20). Septal panniculitis was present in 89.2% of cases evaluated histopathologically. Mixed or lobular panniculitis was present in 35.7% of Behçet's disease patients with EN-like lesions. Vasculitis was also noted in 35.7% of Behçet's disease patients.

CONCLUSIONS

Our data confirm the predominance of upper respiratory tract infections and Behçet's disease among patients with EN in Turkey. Behçet's disease patients presenting with EN-like lesions may show mixed panniculitis and vasculitis, whereas classic EN patients predominantly show septal panniculitis.

Erythema nodosum-like rash in a COVID-19 patient: A case report

Coronavirus 2019 (COVID-19) is a viral disease first described in Wuhan, China, which has quickly emerged as a global pandemic with a myriad of manifestations including dermatologic (Li My et al., n.d.; Gottlieb and Long, 2020 [1,2]). A variety of cutaneous symptoms have presented throughout various stages of the disease (Marzano, 2020; Recalcati, n.d.; Henry et al., n.d.; Fernandez-Nieto et al., n.d.; Quintana-Castanedo et al., n.d. [3-5,7,8]). We describe a case of a female patient who presented with an Erythema Nodosum-like exanthema likely secondary to COVID-19. The patient described tested positive for COVID-19 three days prior to presentation for the rash with minimal other symptoms of COVID-19. Given the high infectivity rate as well as multisystem presentation, it is important to continue to report on novel presentations of the virus for early identification and treatment of complications.

Erythema nodosum as a cutaneous manifestation of COVID-19 infection

Erythema nodosum (EN) is a common dermatological manifestation with many different aetiologies. Often however, the aetiology remains unidentified. We present here a 42-year-old male patient with an EN that is due to an acute COVID-19 infection. Most of the usual aetiologies were excluded by laboratory testing and imaging studies. This case is, to our knowledge, the first report of this cutaneous manifestation in the context of a COVID-19 infection. The EN was successfully treated with the disappearance of the COVID-19 infection and topical corticosteroids.

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.

Occurrence of skin manifestations in patients of the Swiss Inflammatory Bowel Disease Cohort Study

BACKGROUND/AIMS

Extraintestinal cutaneous manifestations of IBD represent a severe disease complication and an early and accurate treatment might positively influence the disease course. Using the patient collective of the Swiss IBD Cohort Study (SIBDCS), we analysed epidemiological as well as clinical factors being associated with the onset of pyoderma gangrenosum, erythema nodosum and aphthous ulcers in IBD patients.

METHODS

We included 3266 SIBDCs patients, 1840 with Crohn's disease (CD) and 1426 with ulcerative colitis (UC) or IBD unclassified (IBDU) and analysed the association of cutaneous manifestations with age, age at diagnosis time, type of disease, gender, family history, HLA-allotype, smoking, intestinal disease activity, therapy and other extraintestinal manifestations (EIM).

RESULTS

354 CD patients and 136 UC/IBDU patients presented with skin manifestations at any time during their disease course. In both, CD and UC, female gender and younger age at IBD diagnosis were significantly associated with extraintestinal skin manifestations. For CD, we also detected a positive family history as associated factor. As an indicator of more intensive intestinal disease activity, patients with cutaneous manifestations of IBD needed more frequently therapy with antibiotics, steroids, immunomodulators and anti-TNF. Multivariate analysis revealed female gender, younger age at diagnosis and presence of other extraintestinal manifestations as factors being associated with skin EIM in IBD patients and anti-TNF as well as immunomodulatory treatment in CD patients.

CONCLUSION

Our results suggest that young females with a positive family history of IBD might be at increased risk for the onset of skin manifestations and require a careful screening for such complications.

Erythema nodosum and sarcoid granulomas - letting the cat out of the bag

A 41-year-old woman presented with a violaceous papule on the dorsum of the hand, large ipsilateral axillary lymphadenopathy, and tender, erythematous, subcutaneous nodules on the legs. Accompanying signs included fever, ankle swelling, and bilateral red eye. She recalled having a previous exposure to kittens one month before and had a positive family history for sarcoidosis. Histological examination of the hand lesion showed sarcoidal granulomas with positive Bartonella henselae DNA, whereas a biopsy done on the leg nodules was compatible with erythema nodosum. Cat scratch disease (CSD) typically presents as a tender regional lymphadenopathy preceded by an inoculation papule with spontaneous resolution occurring between 8-16 weeks. Cutaneous manifestations of CSD are rare, with erythema nodosum accompanying only 0.6% of cases. Although speculative, the background of a positive family history for sarcoidosis may explain the atypical presentation of this case, with red eye, persistent arthralgia, and associated sarcoidal granulomas.

Clinical, Epidemiological, and Etiological Changes in Erythema Nodosum

BACKGROUND

Erythema nodosum (EN) is the most common type of panniculitis, commonly secondary to infectious diseases.

OBJECTIVES

To elucidate the causative factors and the clinical presentation of patients with EN (2004-2014) and to compare their data to those reported in a previous study.

METHODS

A retrospective study was conducted of all patients diagnosed with EN who were hospitalized at Soroka University Medical Center (2004-2014). The clinical, demographic, and laboratory characteristics of the patients were compared to those in a cohort of patients diagnosed with EN from 1973-1982.

RESULTS

The study comprised 45 patients with a diagnosis of EN. The most common symptoms of patients hospitalized with EN were arthritis or arthralgia (27% of patients). Patients with EN, compared to those reported in 1987, has significantly lower rates of fever (18% vs. 62% P < 0.001), streptococcal infection (16% vs. 44%, P = 0.003), and joint involvement (27% vs. 66%, P < 0.001). In addition, fewer patients had idiopathic causes of EN (9% vs. 32%, P = 0.006).

CONCLUSIONS

In the past decades, clinical, epidemiological, and etiological changes have occurred in EN patients. The lowering in rate of fever, streptococcal infection, and joint involvement in patients with EN are probably explained by improvements in socioeconomic conditions. The significantly decreasing rate of idiopathic causes of EN is possibly due to the greater diagnostic accuracy of modern medicine. The results of the present study demonstrate the impact of improvements in socioeconomic conditions and access to healthcare on disease presentation.

Extravascular manifestations of Takayasu arteritis: focusing on the features shared with spondyloarthritis

BACKGROUND

Takayasu arteritis (TAK) is a systemic disease characterized by large vessel involvement. Although the vascular characteristics of TAK are well characterized, there is no well-organized study demonstrating the extravascular manifestations of TAK. We aimed to evaluate the characteristics of extravascular manifestations of TAK, and to identify the association between vascular and extravascular manifestations of TAK.

METHODS

TAK patients from two independent cohorts between January 2012 and October 2017 were included in the study. Patient characteristics were retrospectively collected from the electronic dataset. The computed tomography scans of all subjects were reviewed to evaluate the pattern of vascular involvement and presence of sacroiliitis. Clinical findings including uveitis, skin lesions, oral ulcers, arthritis, and inflammatory bowel disease (IBD) were reviewed. Logistic regression analysis was performed to evaluate the association between vascular and extravascular manifestations.

RESULTS

For the 268 TAK patients, the mean age at diagnosis was 41.2 ± 14.2 years and 88.1% were female. The extravascular manifestation of TAK was observed in 19.0% of patients, the most common being arthritis including sacroiliitis (11.9%) followed by recurrent oral ulcers (8.6%) and IBD (2.6%). A multivariate logistic regression analysis revealed type IIB vascular involvement (adjusted odds ratio (OR) 2.956, 95% confidence interval (CI) 1.337-6.537, p = 0.007) and the erythrocyte sedimentation rate (ESR) (adjusted OR 1.014, 95% CI 1.003-1.025, p = 0.012) as significantly associated with the presence of axial and peripheral arthritis.

CONCLUSIONS

Extravascular manifestations of TAK were observed in up to one-fifth of patients. The most common extravascular manifestation was arthritis, which was associated with a type IIB vascular involvement pattern and a high ESR.

Acute myeloid leukemia presenting as erythema nodosum: A case report

RATIONALE

Erythema nodosum (EN), a type of septal panniculitis, could be a rare nonspecific cutaneous presentation of acute myeloid leukemia (AML).

PATIENT CONCERNS

A 58-year-old Chinese female was admitted for a 4-week history of painful cutaneous lesions, accompanied by a sternal pain and fever. The lesions once resolved spontaneously but then recurred. Physical examination revealed warm, tender, indurated, rounded, erythematous to violaceous nodules in bilateral lower extremities, ranging in diameter from 1 to 6 cm. Blood marrow examination was compatible with AML-M2.

DIAGNOSES

AML-M2 presenting as EN.

INTERVENTIONS

Daunorubicin and cytarabine were used in induction chemotherapy. The patient achieved complete remission and her skin lesions disappeared simultaneously. Six courses of consolidation chemotherapy were conducted in the following 6 months.

OUTCOMES

The patient died due to AML relapse.

LESSONS

The case strengthens the awareness of cutaneous involvement of AML and raises oncological vigilance in patients with EN.

T-cell regulation in Erythema Nodosum Leprosum

Leprosy is a disease caused by Mycobacterium leprae where the clinical spectrum correlates with the patient immune response. Erythema Nodosum Leprosum (ENL) is an immune-mediated inflammatory complication, which causes significant morbidity in affected leprosy patients. The underlying cause of ENL is not conclusively known. However, immune-complexes and cell-mediated immunity have been suggested in the pathogenesis of ENL. The aim of this study was to investigate the regulatory T-cells in patients with ENL. Forty-six untreated patients with ENL and 31 non-reactional lepromatous leprosy (LL) patient controls visiting ALERT Hospital, Ethiopia were enrolled to the study. Blood samples were obtained before, during and after prednisolone treatment of ENL cases. Peripheral blood mononuclear cells (PBMCs) were isolated and used for immunophenotyping of regulatory T-cells by flow cytometry. Five markers: CD3, CD4 or CD8, CD25, CD27 and FoxP3 were used to define CD4⁺ and CD8⁺ regulatory T-cells. Clinical and histopathological data were obtained as supplementary information. All patients had been followed for 28 weeks. Patients with ENL reactions had a lower percentage of CD4⁺ regulatory T-cells (1.7%) than LL patient controls (3.8%) at diagnosis of ENL before treatment. After treatment, the percentage of CD4⁺regulatory T-cells was not significantly different between the two groups. The percentage of CD8⁺ regulatory T-cells was not significantly different in ENL and LL controls before and after treatment. Furthermore, patients with ENL had higher percentage of CD4⁺ T-ells and CD4⁺/CD8⁺ T-cells ratio than LL patient controls before treatment. The expression of CD25 on CD4⁺ and CD8⁺ T-cells was not significantly different in ENL and LL controls suggesting that CD25 expression is not associated with ENL reactions while FoxP3 expression on CD4⁺ T-cells was significantly lower in patients with ENL than in LL controls. We also found that prednisolone treatment of patients with ENL reactions suppresses CD4⁺ T-cell but not CD8⁺ T-cell frequencies. Hence, ENL is associated with lower levels of T regulatory cells and higher CD4⁺/CD8⁺ T-cell ratio. We suggest that this loss of regulation is one of the causes of ENL.

Leprosy reactions (Type 1 and 2) are important causes of nerve damage and illness. Erythema Nodosum Leprosum (ENL) also called type 2 reaction is a severe systemic immune-mediated complication of borderline and lepromatous leprosy. ENL causes high morbidity and thus requires immediate medical attention. We recruited 77 untreated patients with lepromatous leprosy (46 patients with ENL reactions and 31 patients without ENL reactions) in Ethiopia to better define the immune regulation process in patients with ENL reactions. We took blood samples at 3 time points (before, during and after prednisolone treatment) and measured regulatory T-cells at each time point. Patients with ENL reactions had a lower percentage of CD4⁺ regulatory T-cells than in non-reactional LL patient controls before treatment. Patients with ENL reactions had higher percentage of CD4⁺ T- cells and CD4⁺/CD8⁺ ratio than LL patient controls before treatment. These experiments indicate the need to explore ways of restoring regulatory T-cells in patients with ENL reactions to control the undesired outcome of the reaction.

[Erythema nodosum as a reaction pattern: a broad spectrum of underlying causes]

Erythema nodosum is a skin disorder that is characterised by the presence of painful erythematous nodules and plaques, mainly located on the shins. This disorder is associated with comorbidities and can be considered as an aspecific reaction pattern to a broad range of causes. However, an idiopathic variant also exists, which occurs in 22-72% of cases. Erythema nodosum is pre-eminently a skin disease which, due to its multifactorial pathogenesis, occurs in a wider field than dermatology alone. Therefore, knowledge of this disorder is important for all practicing physicians. To illustrate this we describe three patients with erythema nodosum attributable to different causes.

[Erythema nodosum : a panniculitis of diverse origins]

Erythema nodosum is an acute nodular panniculitis, mainly affecting young women. Diverse etiologies are evoked, but the most frequent are sarcoidosis (Löfgren syndrome), streptococcal infections, yersiniosis and inflammatory enteropathies. Antalgic drugs and rest are usually adequate in this condition, which is spontaneously of favourable evolution. Treatment of the cause is open to discussion, considering their lack of effect on the evolution of erythema nodosum.

[Erythema nodosum: Analysis of 91 hospitalized patients]

BACKGROUND

Erythema Nodosum (EN) is an acute nodular erythematous cutaneous eruption. It is presumed to be a hypersensitivity reaction and it may be idiopathic, or occur in association with diverse diseases and medications.

AIM

To identify the main etiologies of EN among patients admitted to a medicine service of a clinical hospital.

MATERIAL AND METHODS

Analysis of medical records of patients discharged with the diagnosis of EN during a ten years period. Patients were considered to have secondary EN when an underlying condition was found, and to have idiopathic EN when no such condition was found.

RESULTS

One hundred twenty nine patients were identified, but 91, aged 38 ± 14 years (86% females) had available clinical information. The etiology was idiopathic in 32% and secondary in 68% of patients. The leading etiologies were post-Streptococcal in 32%, followed by sarcoidosis in 11%, primary tuberculosis in 7%, Mycoplasma infection in 3%, Bartonella infection in 3%, Behçet's syndrome in 2%, inflammatory bowel disease in 2%, drugs in 1% and other etiologies in 8%. Secondary cases of EN had higher levels of C Reactive Protein and leucocytes than idiopathic cases.

CONCLUSIONS

The distribution of causes in our study population were similar to those reported in the literature (With smaller proportion of idiopathic), as was the man/woman (1/6) ratio, and the preponderance of cases in winter and spring. Infectious diseases were the leading causes of EN in this group of patients, and a reasonable initial approach in the hospital should include a diligent medical history and physical examination, complete blood count, ESR, titles ASO, PPD tuberculin skin test, chest X-ray or CT scan and, where deemed appropriate, specific autoimmune and infectious serology.

[Cutaneous manifestations in inflammatory bowel disease]

Inflammatory bowel disease (IBD), mainly chronic unspecific ulcerative colitis and Crohn's disease have increased in incidence in the last decades. These have multiple extraintestinal manifestations, with those of the skin appearing after the intestinal clinical presentation. These are classified as: granulomatous dermatosis, reactive dermatosis, and those secondary to treatment of IBD, and other dermatosis. This article presents the pathogenesis, clinical approach, treatment and expected evolution of these manifestations.

Elastophagocytosis and Elastolysis in Leprosy

Elastophagocytosis is the engulfment of the elastic fibres by the histiocytes, multinucleated giant cells, or both. The cutaneous lesions showing elastophagocytosis are annular elastolytic giant cell granuloma, actinic keratoses, persistent insect-bite reactions, elastosis perforans serpiginosa, foreign body granuloma. Occasionally, it may occur in infectious diseases like leprosy, granulomatous syphilis, North-American blastomycosis, bacterial folliculitis, and cutaneous leishmaniasis. We report a case of lepromatous leprosy with necrotic erythema nodosum leprosum with secondary anetoderma. Histopathology from the atrophic macule of anetoderma revealed periappendageal, perineural infiltration, elastophagocytosis and reduction in elastic fibres.

Comparison of Efficacy and Safety of Ciclosporin to Prednisolone in the Treatment of Erythema Nodosum Leprosum: Two Randomised, Double Blind, Controlled Pilot Studies in Ethiopia

BACKGROUND

Erythema Nodosum Leprosum (ENL) is a serious complication of leprosy. It is normally treated with high dose steroids, but its recurrent nature leads to prolonged steroid usage and associated side effects. There is little evidence on the efficacy of alternative treatments for ENL, especially for patients who have become steroid resistant or have steroid side effects. These two pilot studies compare the efficacy and side effect profile of ciclosporin plus prednisolone against prednisolone alone in the treatment of patients with either new ENL or chronic and recurrent ENL.

METHODS AND RESULTS

Thirteen patients with new ENL and twenty patients with chronic ENL were recruited into two double-blinded randomised controlled trials. Patients were randomised to receive ciclosporin and prednisolone or prednisolone treatment only. Patients with acute ENL had a delay of 16 weeks in the occurrence of ENL flare-up episode, with less severe flare-ups and decreased requirements for additional prednisolone. Patients with chronic ENL on ciclosporin had the first episode of ENL flare-up 4 weeks earlier than those on prednisolone, as well as more severe ENL flare-ups requiring 2.5 times more additional prednisolone. Adverse events attributable to prednisolone were more common that those attributable to ciclosporin.

CONCLUSIONS

This is the first clinical trial on ENL management set in the African context, and also the first trial in leprosy to use patients' assessment of outcomes. Patients on ciclosporin showed promising results in the management of acute ENL in this small pilot study. But ciclosporin, did not appear to have a significant steroid-sparing effects in patients with chronic ENL, which may have been due to the prolonged use of steroids in these patients in combination with a too rapid decrease of steroids in patients given ciclosporin. Further research is needed to determine whether the promising results of ciclosporin in acute ENL can be reproduced on a larger scale.

Behçet's disease, hospital-based prevalence and manifestations in the Rotterdam area

INTRODUCTION

Behçet's disease is most prevalent in countries along the former Silk Road. Prevalence varies from 70-420 per 100,000 in Turkey, and 13.5-20 and 1-2 per 100,000 in Asia and Western Europe, respectively. Additionally, disease severity and morbidity might be correlated with ethnicity. We studied demography and morbidity in the Dutch cohort of patients with Behçet's disease and compared those with known figures.

PATIENTS AND METHODS

The prevalence of Behçet's patients in the Rotterdam area was determined by comparing the total number of patients within the ethnic population with the number of patients diagnosed with Behçet's disease. Patient files of the Erasmus University Medical Centre (Erasmus MC) were reviewed for morbidity figures and compared with existing data.

RESULTS

In total 84 Behçet's patients of Dutch, Turkish or Moroccan descent were identified in the Rotterdam area. Prevalence of Behçet's disease differed per ethnicity: 1, 71 and 39 per 100,000 for Dutch-Caucasians, Turks, and Moroccans, respectively. These figures are comparable with occurrence in West Turkey and Morocco. Within the studied Erasmus MC cohort no significant differences in morbidity appeared between the ethnic groups. However, uveitis and pustules were significantly more common in the Erasmus MC cohort as compared with UK, German, Turkish and Moroccan cohorts.

DISCUSSION AND CONCLUSIONS

We present the first epidemiological study of Behçet's disease in the Netherlands. The prevalence of Behçet's disease in the studied Dutch region and in countries of ancestry is similar. Morbidity is equally spread, compared with other countries, but uveitis and pustules seem to be more common in the Netherlands.

Resident rounds part III: case report: a papulo- nodular eruption with systemic signs and symptoms

This is a typical presentation of erythema nodosum leprosum in a patient with lepromatous leprosy who recently migrated from Micronesia. The clinical presentation, pathology findings, pathogenesis, and therapeutic options are reviewed here.

Unusual Presentation of Necrotic Erythema Nodosum Leprosum on Scalp: A Case Report

Lepra reactions are acute episodes occurring during the disease process of leprosy and are of 2 types: type 1 or reversal reaction and type 2 reaction or erythema odosumleprosum (ENL). In the episodes of lepra reaction several parts are affected including face and extremities like oral cavity. In the present case report we reported a rare case of lepromatous leprosy with necrotic ENL involving scalp apart from the usual sites. A 58 year old married male presented to us with complaints of spontaneous onset, recurrent eruption of multiple reddish raised painful lesions. Biopsy from the infiltrated skin over the back showed atrophic epidermis, free Grenz zone, diffuse and periadnexal macrophage granulomas with predominant mononuclear infiltrate, appandageal atrophy, fibrosis around the neural structures and leukocytoclastic vasculitis. Fites stain showed strong positivity for M. leprae. His routine blood investigations showed anemia (Hb = 7.8 gm%), neutrophil leukocytosis (TLC = 17,600, DLC = P66L28M4E2) and raised ESR (80 mm in the first hour). These bullous and necrotic lesions in leprosy may be a manifestation of severe type II reactions in patients with very high bacillary load.

[Effectiveness of thalidomide for erythema nodosum leprosum (ENL): retrospective study of 20 Japanese cases in National Sanatrium Oku-Komyoen]

Thalidomide is a TNF-alpha inhibitor and has been administrated for erythema nodosum leprosum (ENL, Type II leprosy reaction) which is one of leprosy reactions and can cause serious illness to patients oflepromatous pole among the immune spectrum. Twenty live cases (at May, 2011) were identified to whom thalidomide had been administrated since 1978 for their ENL reactions. Data were collected from their clinical records in order to evaluate the usage and effectiveness of thalidomide in National Sanatorium Oku-Komyoen, Okayama, Setouchi-city, Japan. Individual data includes bacillary index (BI), total dose, average daily dose, maximum daily dose, minimum daily dose, methods of thalidomide administration and change of symptoms of ENL. Results: No adverse effect was found among 20 cases. Average daily dose of 20 cases was 19 mg. Regarding to the maximum daily dose, in 3 cases (15%) more than 100 mg, in 3 cases (15%) 50 mg, and in 14 cases (70%) less than 40 mg was administrated. Dose was gradually tapered in most cases. From clinical records, thalidomide was found effective for ENL in 19 cases and clinicians concerned were trying to adjust the proper dose of the drug carefully depending on the current symptoms, because there was no guideline of thalidomide administration for ENL. This data suggests that even less than 50-100 mg as the initial daily dose was still effective, though 50-100 mg daily dose is recommended in the current guideline of Japan (2011) and more dose had been administrated in USA and India.

The etiology and clinical manifestation of erythema nodosum in hospitalized children - analysis of 12 cases. Preliminary report

AIM

To analyse etiologic factors and the clinical course of erythema nodosum in hospitalized children.

MATERIAL AND METHODS

A retrospective study of 12 children and young people (7 girls and 5 boys) admitted to the Paediatric Clinic in Zabrze with erythema nodosum was performed from January 2004 to February 2014. The patients' mean age on admission was 11.9 years (2-16).

RESULTS

In ten of the 12 patients elevated CRP was identified - from 10 mg/L to 131.5 mg/L, which is proof of an ongoing inflammatory process. Only two patients had a CRP level below 5 mg/L. Three of the 12 patients were diagnosed with Crohn's Disease, one with diarrhoea (Salmonella was cultured and antigen Rotavirus was found), one with arthritis, one with bilateral cervical lymphadenopathy, three with Streptococcal infection, two had elevated anti-streptolysin O level (ASO).

CONCLUSION

The present research may confirm the hypothesis that EN could be the first sign of systemic diseases. However, it requires further studies because of the limited number of patients.

Erythema Nodosum and Granulomatous Lesions Preceding Acute Myelomonocytic Leukemia

A 65-year-old female with a one-month history of painful eruptions on her lower extremities was admitted to our hospital. Histological examination revealed erythema nodosum (EN), and the patient was treated with oral prednisolone (PSL; 20 mg daily). The eruptions subsided in two weeks. One month later, painful reddish eruptions recurred on her upper limbs and abdomen in addition to her lower extremities. A skin biopsy from an abdominal erythematous plaque revealed a non-caseating granuloma without microorganisms or foreign-body materials. These eruptions also disappeared with treatment with oral PSL (20 mg daily). No underlying disease, including sarcoidosis, diabetes mellitus, or rheumatoid arthritis, was found. However, five months later, the patient developed conspicuous leukocytosis. She was diagnosed with acute myelomonocytic leukemia (M4) and treated with chemotherapy. After complete remission had been achieved, the EN reappeared, in association with an increase in blastic cells in the bone marrow. Serum levels of tumor necrosis factor-alpha and interleukin-1 beta, which are thought to be essential for granuloma formation and induction of EN, were markedly elevated. Physicians must remember that recurrent EN and granulomatous lesions can be a prodromal sign of leukemia.

Erythema Nodosum Induced by the Synergism of Acupuncture Therapy and Flu-Like Infection

A 32-year-old female patient developed erythema nodosum-like lesions at needle prick sites after acupuncture therapy. Over the next few days, she developed similar new lesions over the extremities, trunk and face along with flu-like symptoms. There were neither genital ulcerations nor eye lesions. A skin biopsy specimen from an extremity lesion showed the characteristic findings of erythema nodosum. Treatment with oral potassium iodide at a dose of 750 mg/day was effective, and there has not been any recurrence to date. We diagnosed this case as erythema nodosum induced by a synergism between acupuncture therapy and a flu-like infection.

A new Mucocutaneous Activity Index for Behçet's disease

OBJECTIVES

Patient-reported outcomes are increasingly accepted to be major domains in chronic disorders. The aim of this study was to develop a patient-derived disease activity index in Beh-çet's disease (BD).

METHODS

One hundred and seventy-seven BD patients (M/F: 69/108) were included in the study. Data were collected by clinical examination and a questionnaire regarding a Mucocutaneous Index (MI) with genital ulcer activity (GI), erythema nodosum activity (EI) and the composite index (CI) for oral ulcers, as subscales of it. Self-reported treatment evaluation was carried out as criterion validity. Patients whose symptoms completely disappeared or decreased significantly, were categorised as 'improved group', others were classified as 'non-improved group'.

RESULTS

Among the study group, 79.7% of the patients (n=141) were active, whereas 20.3% were inactive (n=36). Scores of CI, GI, EI and MI score were 0±0 in inactive ones, whereas scores were 5.65±2.36 for CI, 0.81±2.34 for GI, 0.91±2.35 for EI and 6.25±5.1 for MI in actives (p=0.000 for all). MI score was significantly higher in 'non-improved group' (65.5%) compared to 'improved group' (34.5%) (p<0.0001).

CONCLUSIONS

The mucocutaneous activity index may help decision-making process for treatment strategies in BD patients.

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.