Erythema nodosum

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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189 Erythema nodosum

Instruction

Look at this patient’s shins.

Salient features

History

• Elicit a history of:

• fever (may precede the skin lesions by 1–7 days)
• painful nodules
• arthalgias
• sore throat (β-haemolytic streptococcal infection)
• drugs (sulphonamides, penicillins, oral contraceptives)
• GI symptoms (Yersinia enterocolitica infections)
• infections (TB, leprosy, coccidiomycosis, histoplasmosis)
• sarcoidosis.

Remember:

• about half the cases are idiopathic

• lesions can be less intense in coloration, like large pink hives

• lesions appears in crops; consequently, there may lesions in different stages of evolution.

Examination

• Poorly defined, exquisitely tender, erythematous nodules (which are better felt than seen) (Fig. 189.1).

image

Fig. 189.1 Erythema nodosum lesions.

Diagnosis

This patient has tender erythema nodosum (lesions) on the shins caused by the use of oral contraceptives (aetiology).

Questions

How can a definitive diagnosis be obtained?

By a deep wedge biopsy of the tissue.

Advanced-level questions

What is the histology?

Erythema nodosum is a panniculitis, which is an inflammatory reaction in the subcutaneous fat:

• In early lesions, there is widening of the connective tissue septa owing to oedema, fibrin exudation and infiltration by neutrophils

• Later, there is infiltration by lymphocytes, histiocytes, multinucleated giant cells and occasionally eosinophils, associated with septal fibrosis.

Note: Vasculitis is absent.

Mention some examples of panniculitis

• Erythema induratum (associated vasculitis)

• Weber–Christian disease (relapsing febrile nodular panniculitis)

• Factitial panniculitis.

How would you treat these patients?

Local: hot or cold compresses

Systemic: NSAIDs, saturated solution of potassium iodide, corticosteroid therapy, salicylates.

FP Weber (1863–1962), a British physcian who graduated from St Bartholomew’s Hospital, London, and was a keen collector of coins and vases. He was an alpinist, like his father Sir HD Weber (1823–1918), who described Weber syndrome.

Henry A Christian (1876–1951), Professor of Medicine and the first Physician-in-Chief of the Peter Bent Brigham Hospital. He also described histiocytosis X (Hand–Schüller–Christian disease).

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189 Erythema nodosum

Instruction

Look at this patient’s shins.

Salient features

History

• Elicit a history of:

• fever (may precede the skin lesions by 1–7 days)
• painful nodules
• arthalgias
• sore throat (β-haemolytic streptococcal infection)
• drugs (sulphonamides, penicillins, oral contraceptives)
• GI symptoms (Yersinia enterocolitica infections)
• infections (TB, leprosy, coccidiomycosis, histoplasmosis)
• sarcoidosis.

Remember:

• about half the cases are idiopathic

• lesions can be less intense in coloration, like large pink hives

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