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Erythema Nodosum

Title               

Ñ    Erythema Nodosum

Definition

Ñ    Acute, nodular, erythematous eruption

Ñ    Hypersensitivity reaction

Ñ    Associated with systemic diseases, drugs or idiopathic

Pathogenesis

Causes

IS

Ñ    Leprosy

RS

Ñ    Streptococcal infection

Ñ    Tuberculosis

Ñ    Sarcoidosis

LMS

Ñ    Rheumatoid arthritis

Ñ    Rheumatic fever

Ñ    Behcet’s disease

GIT

Ñ    Inflammatory bowel disease

Ñ    Systemic fungal infections

Ñ    Yersinia enterocolitica

HS

Ñ    Lymphoma

Ñ    Leukaemia

RAG

Ñ    Syphilis

Ñ    Lymphogranuloma venereum

Ñ    Pregnancy

Drugs

Ñ    Oral contraceptive pill

Ñ    Sulphonamides

Ñ    Penicillin

Ñ    Anticonvulsants

Ñ    NSAIDs

Ñ    Thiazide diuretics

Pathological Process

Ñ    Delayed hypersensitivity reaction to a variety of antigens

Results in:

Ñ    Septal panniculitis:

Panniculitis refers to inflammation of subcutaneous fat

Clinical Features

History

Age

Ñ    Young adults aged 18-34 years:

Usually

Sex

Ñ    Females > Males

E&M

Ñ    Fever

IS

Ñ    Painful rash:

Within 1-2 days of onset of fever

Ñ    Infection-induced:

Heals within 7 weeks, but active disease may last up to 18 weeks

Ñ    Idiopathic cases:

30% may last more than 6 months.

LMS

Ñ    Arthralgia

Past Illnesses

Ñ    Relevant underlying illness

Drug History

Ñ    Relevant drug

Examination

E&M

Ñ    Fever

IS

Ñ    Red tender nodules

Ñ    Borders poorly defined

Ñ    2-6 cm

Ñ    First week:

Tense, hard, and painful

Ñ    Second week:

May become fluctuant

Ñ    Individual lesions last approximately 2 weeks

Ñ    Occasionally, new lesions continue to appear for 3-6 weeks

Ñ    Characteristically anterior leg

Ñ    May appear on any surface

RS

Ñ    Hilar lymphadenopathy

LMS

Ñ    Synovitis

Investigations

Fluids

Blood

Haematology

Ñ    Erythrocyte sedimentation rate:

Very high

Immunology

Ñ    Antistreptolysin O titre:

Elevated

Throat Swab

Ñ    Group A beta-haemolytic streptococcal infection

Faeces

Microbiology

Ñ    Stool culture:

Yersinia

Imaging

Chest X-ray

Ñ    Hilar lymphadenopathy

Tissue Diagnosis

Skin

Biopsy

Ñ    Septal panniculitis

Ñ    The septa of subcutaneous fat are thickened:

Usually

Ñ    Lymphohistiocytic infiltrate is noted in the septum and in small and medium-sized vessels

Ñ    Periseptal fibrosis, giant cells, and granulation tissue appear

Ñ    Miescher granulomas:

Are hallmarks

Small well-defined nodular aggregates of histiocytes around a central stellate cleft

Scattered throughout the lesions

Management

Symptom Relief

Drugs

Ñ    Non-steroidal anti inflammatory drugs

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