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Erythema nodosum and tuberculosis
452
TUBERCLE
TUBERCLE. J U L Y , 1932.
Erythema lqodosum and Tuberculosis. Many writers have commented on the possible relationship between erythema nodosum and tuberculosis. The former is regarded as an allergic phenomenon which may be significant not only of the onset of tuberculosis but of other infective diseases. It has further been noted that it tends to occur about the time that a patient develops a positive tuberculin reaction. H o w far it can be regarded as pathognomonie of the onset of tuberculosis, however, is still an open question. An extremely interesting instance of multiple cases has recently been published by Dr. A. Landau [1]. Dr. Landau has recorded an instance of a school-class endemic of the disease occurring in Gothenburg in 1931. The class consisted of 31 girls aged 11-19~. Four cases of ery~hema nodosum occurred in the class at the same time. Of the 31 girls, 29 reacted to tuberculin (Mantoux) and one of these revealed a right-sided cavernous pulmonary tuberculosis with tubercle bacilli in the sputum. The general condition of this girl was excellent, free from fever; she was the stoutest in the class and gave no impression of suffering from active tuberculosis. Besides the four girls who had erythema nodosum, one of whom subsequently developed pleurisy, four others showed increase in sedimentation reaction and fresh hilum gland enlargements. The case of frank open pulmonary tuberculosis discovered on examination of the whole class was found not to have missed school for a single day all the term but had had a " c o l d " for a short period four to six weeks before the four cases of erythema nodosum occurred and had coughed so much that the teacher had advised her to keep away from school, which the girl had not done. In order to answer the question
[July, 1932
whether eryt,hema nodosum or erythema exudativum multiforme is an expression or precursor of active tuberculosis, Dr. A. Cedercreutz [2] has made an enquiry into the subsequent fate of patients in private and hospital practice who, before 1910, had suffered from one or other of these skin diseases. Of the 63 patients with erythema nodosum, only 10 were males, whereas of the 78 patients with erythema exudativum multiforme, as many as 40 were males. The seasonal incidence of both diseases, with a comparatively high frequency in the colder months of the year, was that observed in other countries. The afterhistories of 26 of the erythema nodosum patients were ascertained, and nine were found to have died. But only two of these deaths were notified as having been due to pulmonary tuberculosis. The fate of 36 of the 78 patients with erytbema exudativum multiforme was ascertained, and it was found that 20 of them had died. But among these 9.0 cases there were only five in which the cause of death had been notified as being pulmonary tuberculosis. Cedercreutz admits that his figures are too small to justify sweeping conclusions; but they certainly suggest that the chances of erythema nodosum being followed by active pulmonary tuberculosis are not very great. Dr. H. Ernberg [3], who is in charge of the Sachs Children's Hospital in Stockholm, rejects the theory according to which erythema nodosum is an acute infectious disease sui gener~s, related, perhaps, to rheumatic fever. He refers to a study published some years ago by Wiborg, who had observed many cases within a short interval of time in a country district in Norway. He interpreted this epidemic as evidence of the disease being a nosological entity, independent of tuberculosis. This study has since been quoted in the literature, but when Dr. Ernberg met Wiborg in 1930, it transpired that a school teacher, suffering from open pulmonary tuberculosis, had subsequently been held responsible for this outbreak, and V~riborg had changed his views as to the non-tuberculous genesis of this complaint. Ernberg has observed
J u l y , 1932]
E~u
~ODOSUM
m o r e t h a n 200 e a s e s of e r y t h e m a n o d o s u m w h i c h i n c l u d e 39 consecutive cases e x a m i n e d b y t h e X - r a y s . All 39 were t u b e r c u l i n - p o s i t i v e , a n d as m a n y as 35 s h o w e d s o m e degree of pathological hilum changes. The histories, clinical findings a n d positive t u b e r c u l i n r e a c t i o n s left little d o u b t in his m i n d as to t h e t u b e r c u l o u s c h a r a c t e r of the h i l u m changes. E v e n in t h e four cases in w h i c h t h e y w e r e n o t demonstrable, t h e r e were o t h e r signs (phlyet e n u l a r c o n j u n c t i v i t i s in two eases) suggestive of t u b e r c u l o s i s . F a i l u r e to d e m o n s t r a t e t u b e r c l e bacilli in the i n f i l t r a t e d skin, a n d t h e s i m i l a r i t y of t h e h i s t o l o g i c a l s t r u c t u r e of this skin to t h a t of skin w h i c h h a s b e c o m e infiltrated by a r e a c t i o n to an i n j e c t i o n of t u b e r c u l i n , have l e d E r n b e r g to con-
A~D TUBERCULOSIS
453
elude t h a t e r y t h e m a n o d o s u m is n o t a t u b e r c u l o u s skin d i s e a s e s t r i c t l y speaking, but is r a t h e r to be r e g a r d e d as an a u t o g e n o u s t u b e r c u l i n reaction. The logical sequel to t h i s conclusion is t h a t a ease of e r y t h e m a n o d o s u m should give the signal for an X - r a y e x a m i n a t i o n of the p a t i e n t himself, a n d a search for the source of infection a m o n g his contacts. T h e p a t i e n t s h o u l d also be t r e a t e d as suffering from tuberculosis, the p r o g n o s i s of w h i c h is, however, good. REFEREIqCES. [i] LANDAU, A. 7, 77.
Arch. Dis. in Childhood, 1932,
[2] CEDERCREUTZ, A. Finska Ldkares~llska. Tets Handlingar, 1931, 73, 61. [3] ERNBEBG, H. 1bid, 1932, r/~, 164.
B O O K N O T I C E S AND A B S T R A C T S . Book Notices.
an a v e r s e , 6"7 p e r cent. of raw m i l k sold as food c o n t a i n s living tubercle R e p o r t of a S p e c i a l C o m m i t t e e appoin- bacilli. The evidence p r e s e n t e d does t e d by t h e P e o p l e ' s L e a g u e of H e a l t h to not point to a n y definite d i m i n u t i o n in m a k e a S u r v e y oI T u b e r c u l o s i s of Bovine r e c e n t y e a r s in the a m o u n t of bovine Origin in G r e a t B r i t a i n . The People's League of tIealth, Lvndon. 1932. Pp. 44. tubercle in c a t t l e or m a n (see s t a t i s t s page 451). E r a d i c a t i o n of t u b e r c u l o s i s Price ls. 6d. from our d a i r y herds, at one swoop, m a y not be a p r a c t i c a l m e a s u r e , b u t legal T h e evidence r e g a r d i n g t h e r a v a g e s of bovine t u b e r c u l o s i s b r o u g h t t o g e t h e r powers now exist to a p p l y m e a s u r e s of in this s u r v e y is p r e s e n t e d with great control, and t h e special c o m m i t t e e urge this with no u n c e r t a i n voice. W e m o d e r a t i o n . R e p o r t s a r e m a d e by two c o m m i t t e e s . T h e first d e a l s w i t h t h e read, " The use of p a s t e u r i s e d milk in incidence in t h i s c o u n t r y of bovine large cities, both in t h i s c o u n t r y and in t u b e r c u l o s i s in cattle, in r a w milk as the U n i t e d S t a t e s of A m e r i c a , has been followed by a r e d u c t i o n in the incidence sold, a n d in h u m a n b e i n g s ; t h e second is c o n c e r n e d w i t h m e a n s for e r a d i c a t i n g of cases of h u m a n tuberculosis of bovine origin a n d by a d i m i n u t i o n of e p i d e m i c s the disease. I t is s t a t e d t h a t a b o u t 2,000 d e a t h s in E n g l a n d a n d Wales, of m i l k - b o r n e diseases such, for m o s t l y in c h i l d r e n , occur a n n u a l l y from example, as d i p h t h e r i a , typhoid, p a r a t h i s c a u s e ; while at l e a s t 4,000 fresh t y p h o i d fever, scarlet fever, septic sore cases develop each year, c a u s i n g an t h r o a t and u n d u l a n t fever. The a m o u n t i m m e n s e a m o u n t of suffering, i n v a l i d i t y of evidence s u p p o r t i n g this s t a t e m e n t , both from this c o u n t r y and from t h e a n d often p e r m a n e n t d e f o r m i t y , and f u r t h e r t h a t 40 p e r c e n t . of t h e cows in o t h e r side of t h e A t l a n t i c , is considerthis c o u n t r y are infected w i t h the able." Two g r a d e s of milk only are t u b e r c l e bacillus, even t h o u g h only a r e c o m m e n d e d : (1) R a w milk from m i n o r i t y are in an a c t i v e l y infective tubercle-free h e r d s ; a n d (2) p a s t e u r i s e d condition at a n y one t i m e ; a n d that, on or h e a t - t r e a t e d milk.
TUBERCLE
TUBERCLE. J U L Y , 1932.
Erythema lqodosum and Tuberculosis. Many writers have commented on the possible relationship between erythema nodosum and tuberculosis. The former is regarded as an allergic phenomenon which may be significant not only of the onset of tuberculosis but of other infective diseases. It has further been noted that it tends to occur about the time that a patient develops a positive tuberculin reaction. H o w far it can be regarded as pathognomonie of the onset of tuberculosis, however, is still an open question. An extremely interesting instance of multiple cases has recently been published by Dr. A. Landau [1]. Dr. Landau has recorded an instance of a school-class endemic of the disease occurring in Gothenburg in 1931. The class consisted of 31 girls aged 11-19~. Four cases of ery~hema nodosum occurred in the class at the same time. Of the 31 girls, 29 reacted to tuberculin (Mantoux) and one of these revealed a right-sided cavernous pulmonary tuberculosis with tubercle bacilli in the sputum. The general condition of this girl was excellent, free from fever; she was the stoutest in the class and gave no impression of suffering from active tuberculosis. Besides the four girls who had erythema nodosum, one of whom subsequently developed pleurisy, four others showed increase in sedimentation reaction and fresh hilum gland enlargements. The case of frank open pulmonary tuberculosis discovered on examination of the whole class was found not to have missed school for a single day all the term but had had a " c o l d " for a short period four to six weeks before the four cases of erythema nodosum occurred and had coughed so much that the teacher had advised her to keep away from school, which the girl had not done. In order to answer the question
[July, 1932
whether eryt,hema nodosum or erythema exudativum multiforme is an expression or precursor of active tuberculosis, Dr. A. Cedercreutz [2] has made an enquiry into the subsequent fate of patients in private and hospital practice who, before 1910, had suffered from one or other of these skin diseases. Of the 63 patients with erythema nodosum, only 10 were males, whereas of the 78 patients with erythema exudativum multiforme, as many as 40 were males. The seasonal incidence of both diseases, with a comparatively high frequency in the colder months of the year, was that observed in other countries. The afterhistories of 26 of the erythema nodosum patients were ascertained, and nine were found to have died. But only two of these deaths were notified as having been due to pulmonary tuberculosis. The fate of 36 of the 78 patients with erytbema exudativum multiforme was ascertained, and it was found that 20 of them had died. But among these 9.0 cases there were only five in which the cause of death had been notified as being pulmonary tuberculosis. Cedercreutz admits that his figures are too small to justify sweeping conclusions; but they certainly suggest that the chances of erythema nodosum being followed by active pulmonary tuberculosis are not very great. Dr. H. Ernberg [3], who is in charge of the Sachs Children's Hospital in Stockholm, rejects the theory according to which erythema nodosum is an acute infectious disease sui gener~s, related, perhaps, to rheumatic fever. He refers to a study published some years ago by Wiborg, who had observed many cases within a short interval of time in a country district in Norway. He interpreted this epidemic as evidence of the disease being a nosological entity, independent of tuberculosis. This study has since been quoted in the literature, but when Dr. Ernberg met Wiborg in 1930, it transpired that a school teacher, suffering from open pulmonary tuberculosis, had subsequently been held responsible for this outbreak, and V~riborg had changed his views as to the non-tuberculous genesis of this complaint. Ernberg has observed
J u l y , 1932]
E~u
~ODOSUM
m o r e t h a n 200 e a s e s of e r y t h e m a n o d o s u m w h i c h i n c l u d e 39 consecutive cases e x a m i n e d b y t h e X - r a y s . All 39 were t u b e r c u l i n - p o s i t i v e , a n d as m a n y as 35 s h o w e d s o m e degree of pathological hilum changes. The histories, clinical findings a n d positive t u b e r c u l i n r e a c t i o n s left little d o u b t in his m i n d as to t h e t u b e r c u l o u s c h a r a c t e r of the h i l u m changes. E v e n in t h e four cases in w h i c h t h e y w e r e n o t demonstrable, t h e r e were o t h e r signs (phlyet e n u l a r c o n j u n c t i v i t i s in two eases) suggestive of t u b e r c u l o s i s . F a i l u r e to d e m o n s t r a t e t u b e r c l e bacilli in the i n f i l t r a t e d skin, a n d t h e s i m i l a r i t y of t h e h i s t o l o g i c a l s t r u c t u r e of this skin to t h a t of skin w h i c h h a s b e c o m e infiltrated by a r e a c t i o n to an i n j e c t i o n of t u b e r c u l i n , have l e d E r n b e r g to con-
A~D TUBERCULOSIS
453
elude t h a t e r y t h e m a n o d o s u m is n o t a t u b e r c u l o u s skin d i s e a s e s t r i c t l y speaking, but is r a t h e r to be r e g a r d e d as an a u t o g e n o u s t u b e r c u l i n reaction. The logical sequel to t h i s conclusion is t h a t a ease of e r y t h e m a n o d o s u m should give the signal for an X - r a y e x a m i n a t i o n of the p a t i e n t himself, a n d a search for the source of infection a m o n g his contacts. T h e p a t i e n t s h o u l d also be t r e a t e d as suffering from tuberculosis, the p r o g n o s i s of w h i c h is, however, good. REFEREIqCES. [i] LANDAU, A. 7, 77.
Arch. Dis. in Childhood, 1932,
[2] CEDERCREUTZ, A. Finska Ldkares~llska. Tets Handlingar, 1931, 73, 61. [3] ERNBEBG, H. 1bid, 1932, r/~, 164.
B O O K N O T I C E S AND A B S T R A C T S . Book Notices.
an a v e r s e , 6"7 p e r cent. of raw m i l k sold as food c o n t a i n s living tubercle R e p o r t of a S p e c i a l C o m m i t t e e appoin- bacilli. The evidence p r e s e n t e d does t e d by t h e P e o p l e ' s L e a g u e of H e a l t h to not point to a n y definite d i m i n u t i o n in m a k e a S u r v e y oI T u b e r c u l o s i s of Bovine r e c e n t y e a r s in the a m o u n t of bovine Origin in G r e a t B r i t a i n . The People's League of tIealth, Lvndon. 1932. Pp. 44. tubercle in c a t t l e or m a n (see s t a t i s t s page 451). E r a d i c a t i o n of t u b e r c u l o s i s Price ls. 6d. from our d a i r y herds, at one swoop, m a y not be a p r a c t i c a l m e a s u r e , b u t legal T h e evidence r e g a r d i n g t h e r a v a g e s of bovine t u b e r c u l o s i s b r o u g h t t o g e t h e r powers now exist to a p p l y m e a s u r e s of in this s u r v e y is p r e s e n t e d with great control, and t h e special c o m m i t t e e urge this with no u n c e r t a i n voice. W e m o d e r a t i o n . R e p o r t s a r e m a d e by two c o m m i t t e e s . T h e first d e a l s w i t h t h e read, " The use of p a s t e u r i s e d milk in incidence in t h i s c o u n t r y of bovine large cities, both in t h i s c o u n t r y and in t u b e r c u l o s i s in cattle, in r a w milk as the U n i t e d S t a t e s of A m e r i c a , has been followed by a r e d u c t i o n in the incidence sold, a n d in h u m a n b e i n g s ; t h e second is c o n c e r n e d w i t h m e a n s for e r a d i c a t i n g of cases of h u m a n tuberculosis of bovine origin a n d by a d i m i n u t i o n of e p i d e m i c s the disease. I t is s t a t e d t h a t a b o u t 2,000 d e a t h s in E n g l a n d a n d Wales, of m i l k - b o r n e diseases such, for m o s t l y in c h i l d r e n , occur a n n u a l l y from example, as d i p h t h e r i a , typhoid, p a r a t h i s c a u s e ; while at l e a s t 4,000 fresh t y p h o i d fever, scarlet fever, septic sore cases develop each year, c a u s i n g an t h r o a t and u n d u l a n t fever. The a m o u n t i m m e n s e a m o u n t of suffering, i n v a l i d i t y of evidence s u p p o r t i n g this s t a t e m e n t , both from this c o u n t r y and from t h e a n d often p e r m a n e n t d e f o r m i t y , and f u r t h e r t h a t 40 p e r c e n t . of t h e cows in o t h e r side of t h e A t l a n t i c , is considerthis c o u n t r y are infected w i t h the able." Two g r a d e s of milk only are t u b e r c l e bacillus, even t h o u g h only a r e c o m m e n d e d : (1) R a w milk from m i n o r i t y are in an a c t i v e l y infective tubercle-free h e r d s ; a n d (2) p a s t e u r i s e d condition at a n y one t i m e ; a n d that, on or h e a t - t r e a t e d milk.