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Erythema nodosum: presenting feature of primary pulmonary tuberculosis
Pediatric Infectious Disease 2012 April–June Volume 4, Number 2; pp. 91–93
Big Picture
Erythema nodosum: presenting feature of primary pulmonary tuberculosis Ashok Kapse
INTRODUCTION Characterized as tender erytheamatous bumps commonly on the tibial shin, erythema nodosum (EN) is an uncommon yet interesting presentation in pediatric clinical practice. Tuberculosis (TB) is one of the recognized causes. Histologically EN is a panniculitis, commonly involving shins, with occasional spread to the thighs or arms.1 Lesions evolve as inflammatory, painful and tender cutaneous and subcutaneous bilateral red nodules. Nodules never progress to ulceration or scarring and tend to resolve completely, however little bruised appearance in later stage is not uncommon.2 Although may be idiopathic, EN in general is a marker of systemic inflammatory disorder, infections, or drugs; therefore it is imperative to diligently seek for underlying condition. Hereby I present a case of EN as the leading symptom of primary pulmonary TB.
CASE An 11-year-old female presented with complaint of painful skin rash over both legs for the past 10 days. She had lowgrade fever associated with weakness. She did not have cough, urinary symptom, and there was no history of pain anywhere. Her appetite was normal and there was no weight loss. On examination, there were multiple erythematous papulo-nodular, mildly tender skin lesions over both shins (Figure 1). There was no hepatosplenomegaly, lymphadenopathy, joint pain and swelling, and rash of any other kind. The cardiovascular, chest, and abdominal examination were unremarkable. Blood investigations showed normal blood counts slightly elevated erythrocyte sedimentation rate (ESR) 38
and C-reactive protein (CRP) 16 and normal antinuclear antibody (ANA). The Mantoux test (MT) was strongly positive (Figure 2), Chest radiograph showed noticeable left hilar lymphadenopathy (Figure 3). In view of the positive MT and radiological evidence of TB, anti-tuberculosis drugs (H + R + Z) were started on outpatient department (OPD) basis. A follow-up visit after a fortnight showed significant resolution of nodules: decreasing size, fading of color, and disappearance of pain and tenderness. At the end of months patient became totally asymptomatic; regimen was changed to H + R + E which was continued for 6 months.
DISCUSSION Erythema nodosum is a panniculitis that produces painful nodules on the shins. Histologically lesions show immune complex deposition within dermal vessels. Disease is an immunologically reaction to infection and sometimes to drugs. Malaise, fever, and arthralgia are commonly accompanied with nodules. Females are principally affected. Condition is classified as idiopathic or secondary to other diseases. Some causes of EN are listed in Table 1. The causes of EN may differ as per regions; however, infections constitute significantly.3 In a retrospective study of 106 patients from Spain 34% patients had infections and 22% had sarcoidosis, while 35% cases had no detectable cause. Among infections upper respiratory tract infections constitute major fraction (20%): 13% non-streptococcal, 7% streptococcal; 5% of cases were due to TB. Infections comprised major chunk (26%) of cases in a retrospective study of 75 patients from Singapore. Viral respiratory tract infections and streptococcal pharyngitis were the common infectious causes, while 3% cases were due to TB.4
Consultant Pediatrician, Kapse Children Hospital, Behind Rangupavan, Makaipur, Surat – 395001, Gujarat, India. Correspondence: Dr. Ashok Kapse, email: [email protected] doi: 10.1016/S2212-8328(12)60028-9
ISSN: 2212-8328 Copyright © 2012. The Indian Academy of Pediatrics, Infectious Disease Chapter. All rights reserved.
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Pediatric Infectious Disease 2012 April–June; Vol. 4, No. 2
Figure 1 Nodular swellings on tibial shin.
Kapse
Figure 3 Left hilar lymphadenopathy.
Table 1 Causes of erythema nodosum
Figure 2 Strongly positive Mantoux test.
Erythema nodosum usually occurs during early phase of primary tubercular infection. Bacilli are hardly ever seen in the lesions contrarily high levels of immune complexes are commonly observed in blood suggesting it to be a hypersensitivity phenomenon. It coincides in time with tuberculin conversion, and therefore many times could be the first sign of TB.5 In some cases immune phenomena may reflect as arthralgia. Erythema nodosum generally is a manifestation of systemic diseases; TB is one of the common and treatable causes, hence every patients presenting with EN should always be investigated for TB. Most of the cases resolve with appropriate antitubercular treatment; a non-steroidal anti-inflammatory drug is effective in relieving pain however in rare cases corticosteroids may be needed.
Drugs Penicillin Sulfonamides Systemic diseases Streptococcal infection Viral respiratory infections Tuberculosis Chlamydia Helminthiasis Leprosy Sarcoidosis Inflammatory bowel disease Histoplasmosis Coccidioidomycosis
REFERENCES 1.
Hinds CJ. Intensive Care Medicine. In: Clinical Medicine 3rd edn. Kumar PJ, Clarke ML, eds. Balliere Tindall 1994:709–36.
2.
García-Porrúa C, González-Gay MA, Vázquez-Caruncho M, et al. Erythema nodosum: etiologic and predictive factors in a defined population. Arthritis Rheum 2000;43:584–92.
3.
Psychos DN, Voulgari PV, Skopouli FN, Drosos AA, Moutsopoulos HM. Erythema nodosum: the underlying conditions. Clin Rheumatol 2000;19:212–6.
4.
Tay YK. Erythema nodosum in Singapore. Clin Exp Dermatol 2000;25:377–80.
5.
Wallgren A. The time-table of tuberculosis. Tubercle 1948; 29:245–51.
Big Picture
Erythema nodosum: presenting feature of primary pulmonary tuberculosis Ashok Kapse
INTRODUCTION Characterized as tender erytheamatous bumps commonly on the tibial shin, erythema nodosum (EN) is an uncommon yet interesting presentation in pediatric clinical practice. Tuberculosis (TB) is one of the recognized causes. Histologically EN is a panniculitis, commonly involving shins, with occasional spread to the thighs or arms.1 Lesions evolve as inflammatory, painful and tender cutaneous and subcutaneous bilateral red nodules. Nodules never progress to ulceration or scarring and tend to resolve completely, however little bruised appearance in later stage is not uncommon.2 Although may be idiopathic, EN in general is a marker of systemic inflammatory disorder, infections, or drugs; therefore it is imperative to diligently seek for underlying condition. Hereby I present a case of EN as the leading symptom of primary pulmonary TB.
CASE An 11-year-old female presented with complaint of painful skin rash over both legs for the past 10 days. She had lowgrade fever associated with weakness. She did not have cough, urinary symptom, and there was no history of pain anywhere. Her appetite was normal and there was no weight loss. On examination, there were multiple erythematous papulo-nodular, mildly tender skin lesions over both shins (Figure 1). There was no hepatosplenomegaly, lymphadenopathy, joint pain and swelling, and rash of any other kind. The cardiovascular, chest, and abdominal examination were unremarkable. Blood investigations showed normal blood counts slightly elevated erythrocyte sedimentation rate (ESR) 38
and C-reactive protein (CRP) 16 and normal antinuclear antibody (ANA). The Mantoux test (MT) was strongly positive (Figure 2), Chest radiograph showed noticeable left hilar lymphadenopathy (Figure 3). In view of the positive MT and radiological evidence of TB, anti-tuberculosis drugs (H + R + Z) were started on outpatient department (OPD) basis. A follow-up visit after a fortnight showed significant resolution of nodules: decreasing size, fading of color, and disappearance of pain and tenderness. At the end of months patient became totally asymptomatic; regimen was changed to H + R + E which was continued for 6 months.
DISCUSSION Erythema nodosum is a panniculitis that produces painful nodules on the shins. Histologically lesions show immune complex deposition within dermal vessels. Disease is an immunologically reaction to infection and sometimes to drugs. Malaise, fever, and arthralgia are commonly accompanied with nodules. Females are principally affected. Condition is classified as idiopathic or secondary to other diseases. Some causes of EN are listed in Table 1. The causes of EN may differ as per regions; however, infections constitute significantly.3 In a retrospective study of 106 patients from Spain 34% patients had infections and 22% had sarcoidosis, while 35% cases had no detectable cause. Among infections upper respiratory tract infections constitute major fraction (20%): 13% non-streptococcal, 7% streptococcal; 5% of cases were due to TB. Infections comprised major chunk (26%) of cases in a retrospective study of 75 patients from Singapore. Viral respiratory tract infections and streptococcal pharyngitis were the common infectious causes, while 3% cases were due to TB.4
Consultant Pediatrician, Kapse Children Hospital, Behind Rangupavan, Makaipur, Surat – 395001, Gujarat, India. Correspondence: Dr. Ashok Kapse, email: [email protected] doi: 10.1016/S2212-8328(12)60028-9
ISSN: 2212-8328 Copyright © 2012. The Indian Academy of Pediatrics, Infectious Disease Chapter. All rights reserved.
92
Pediatric Infectious Disease 2012 April–June; Vol. 4, No. 2
Figure 1 Nodular swellings on tibial shin.
Kapse
Figure 3 Left hilar lymphadenopathy.
Table 1 Causes of erythema nodosum
Figure 2 Strongly positive Mantoux test.
Erythema nodosum usually occurs during early phase of primary tubercular infection. Bacilli are hardly ever seen in the lesions contrarily high levels of immune complexes are commonly observed in blood suggesting it to be a hypersensitivity phenomenon. It coincides in time with tuberculin conversion, and therefore many times could be the first sign of TB.5 In some cases immune phenomena may reflect as arthralgia. Erythema nodosum generally is a manifestation of systemic diseases; TB is one of the common and treatable causes, hence every patients presenting with EN should always be investigated for TB. Most of the cases resolve with appropriate antitubercular treatment; a non-steroidal anti-inflammatory drug is effective in relieving pain however in rare cases corticosteroids may be needed.
Drugs Penicillin Sulfonamides Systemic diseases Streptococcal infection Viral respiratory infections Tuberculosis Chlamydia Helminthiasis Leprosy Sarcoidosis Inflammatory bowel disease Histoplasmosis Coccidioidomycosis
REFERENCES 1.
Hinds CJ. Intensive Care Medicine. In: Clinical Medicine 3rd edn. Kumar PJ, Clarke ML, eds. Balliere Tindall 1994:709–36.
2.
García-Porrúa C, González-Gay MA, Vázquez-Caruncho M, et al. Erythema nodosum: etiologic and predictive factors in a defined population. Arthritis Rheum 2000;43:584–92.
3.
Psychos DN, Voulgari PV, Skopouli FN, Drosos AA, Moutsopoulos HM. Erythema nodosum: the underlying conditions. Clin Rheumatol 2000;19:212–6.
4.
Tay YK. Erythema nodosum in Singapore. Clin Exp Dermatol 2000;25:377–80.
5.
Wallgren A. The time-table of tuberculosis. Tubercle 1948; 29:245–51.