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Weber V, Weimann K, Kolm I, Meier-Schiesser B. [Erythema nodosum]. Z Rheumatol 2024:10.1007/s00393-024-01529-4. [PMID: 38884811 DOI: 10.1007/s00393-024-01529-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2024] [Indexed: 06/18/2024]
Abstract
Erythema nodosum (EN) is the most frequently occurring form of acute panniculitis. It is characterized by painful red to livid raised nodules or bumps that typically occur symmetrically in the shin area. The cause of EN is often a reaction of the immune system to various triggers including infections, inflammatory diseases or medications. In approximately half of the cases no trigger can be identified. After treatment of the underlying pathology EN is typically self-limiting.
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Affiliation(s)
- Viktoria Weber
- Dermatologische Klinik, Universitätsspital Zürich, Rämistr. 100, 8901, Zürich, Schweiz
| | - Konstantin Weimann
- Dermatologische Klinik, Universitätsspital Zürich, Rämistr. 100, 8901, Zürich, Schweiz
| | - Isabel Kolm
- Pathologisches Institut, Luzerner Kantonsspital, Spitalstr., 6000, Luzern 16, Schweiz
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Nguyen M, Gross C, Huh SY, Frank A. A Case of Erythema Nodosum in a 20-Year-Old Female During the Postpartum Period. Cureus 2024; 16:e58526. [PMID: 38765407 PMCID: PMC11101599 DOI: 10.7759/cureus.58526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 05/22/2024] Open
Abstract
Erythema nodosum (EN) is the most common form of panniculitis and occurs in about one in 100,000 people. EN typically presents as an eruption of tender, erythematous nodules on the anterior aspect of the legs, although the face, trunk, and arms can also be involved. While the majority of cases are idiopathic, a subset of cases occurs in association with various triggers, including infections, medications, tumors, and autoimmune diseases. Rarely can EN develop in relation to pregnancy, which is thought to provide a physiologic background that favors its development. While pregnancy has been associated with EN in a minority of cases, currently, there is a limited amount of data suggesting that EN can develop in the late postpartum period. Herein, we present a case of a 20-year-old female with a six-week history of painful lesions on her lower extremities. A physical exam revealed multiple tender, erythematous nodules on the anterior aspect of the lower extremities, spanning from the knees to the toes. Laboratory workup showed no other identified triggers of EN in our patient besides pregnancy. Management of EN in our patient involved a low dose, six-day course of prednisone (initial dose of 15 mg/day) and ibuprofen for one week, leading to symptomatic improvement. Our case emphasizes the possibility of EN presenting in the late postpartum period. This case underscores the importance of considering EN in the differential diagnoses for women presenting with compatible lesions postpartum.
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Affiliation(s)
- Martin Nguyen
- Medical School, West Virginia School of Osteopathic Medicine, Lewisburg, USA
| | - Christopher Gross
- Medical School, West Virginia School of Osteopathic Medicine, Lewisburg, USA
| | - Seo Young Huh
- Medical School, West Virginia School of Osteopathic Medicine, Lewisburg, USA
| | - Abigail Frank
- Family Medicine, West Virginia School of Osteopathic Medicine, Lewisburg, USA
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Turner DN, Cortez JL, Garchar ES, Elwood H, Konstantinov NK. Idiopathic lobular panniculitis of pregnancy with resolution following delivery. JAAD Case Rep 2023; 40:126-128. [PMID: 37771353 PMCID: PMC10522936 DOI: 10.1016/j.jdcr.2023.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Affiliation(s)
| | - Jose L. Cortez
- Department of Dermatology, University of New Mexico, Albuquerque, New Mexico
| | - Elizabeth S. Garchar
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico
| | - Hillary Elwood
- Department of Dermatopathology, TriCore Reference Laboratories, Albuquerque, New Mexico
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DiGiacomo D, Rickey L, Kirkorian A, Loomis J, Combs S, Jacobs S, Long M. A 9-Year-Old Girl With Painful "Spider Bites". Clin Pediatr (Phila) 2023; 62:645-648. [PMID: 36415052 DOI: 10.1177/00099228221139426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Daniel DiGiacomo
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Lisa Rickey
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Anna Kirkorian
- Department of Pediatrics, Children's National Hospital, Washington, DC, USA
- Division of Dermatology, Children's National Hospital, Washington, DC, USA
| | - Judyta Loomis
- Department of Pediatrics, Children's National Hospital, Washington, DC, USA
- Division of Diagnostic Imaging and Radiology, Children's National Hospital, Washington, DC, USA
| | - Sarah Combs
- Department of Pediatrics, Children's National Hospital, Washington, DC, USA
- Division of Emergency Medicine, Children's National Hospital, Washington, DC, USA
| | - Shana Jacobs
- Department of Pediatrics, Children's National Hospital, Washington, DC, USA
- Division of Oncology, Children's National Hospital, Washington, DC, USA
| | - Melissa Long
- Department of Pediatrics, Children's National Hospital, Washington, DC, USA
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Limtong P, Suchonwanit P, Chanprapaph K, Rutnin S. Clinicopathological Characteristics Related to Etiologies of Erythema Nodosum: A 10-Year Retrospective Study. Clin Cosmet Investig Dermatol 2021; 14:1819-1829. [PMID: 34876828 PMCID: PMC8643131 DOI: 10.2147/ccid.s343351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/13/2021] [Indexed: 11/25/2022]
Abstract
Background Erythema nodosum (EN) is the most common panniculitis associated with a wide variety of conditions. Updated studies regarding the clinicopathological manifestations related to etiologies of EN and its prognosis are limited. Objective We aimed to explore the clinicopathological features in relation to the etiologies of EN and determine characteristics of disease recurrence and its predictive factors. Methods A total of 169 patients with biopsy-proven EN or septal panniculitis from January 2008 to September 2018 were retrospectively reviewed. Patients were classified as either idiopathic or secondary EN. Patients’ general information, clinical manifestations, investigations, and recurrence of EN were recorded. The details on histopathological findings were reviewed by a blinded dermatopathologist. Results The mean age at diagnosis of EN was 40.6 ± 17.3 years. The majority of patients (85.2%) were female. Idiopathic EN was found in 62.7% of patients. Tuberculosis (23.8%) and drugs (23.8%) were the leading causes of secondary EN. In univariate logistic regression analysis, lesions on upper extremities (p = 0.018), fever (p = 0.003), clinical lymphadenopathy (p < 0.001) favored secondary EN. Histopathologically, the presence of focal peripheral lobular panniculitis with eosinophils was linked to idiopathic EN (p = 0.03). However, multivariable logistic regression analysis failed to demonstrate factors associated with secondary EN. Recurrence was found in 46.6% of patients with no identifiable predictive factors. Conclusion Although no clinical risk factors were associated with the etiology of EN, the histopathological presence of eosinophils in focal peripheral lobular panniculitis suggested idiopathic EN.
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Affiliation(s)
- Preeyachat Limtong
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Poonkiat Suchonwanit
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kumutnart Chanprapaph
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suthinee Rutnin
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Pérez-Garza DM, Chavez-Alvarez S, Ocampo-Candiani J, Gomez-Flores M. Erythema Nodosum: A Practical Approach and Diagnostic Algorithm. Am J Clin Dermatol 2021; 22:367-378. [PMID: 33683567 PMCID: PMC7938036 DOI: 10.1007/s40257-021-00592-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 12/13/2022]
Abstract
Erythema nodosum is the most common form of panniculitis and is characterized by tender erythematous nodules mainly in the lower limbs on the pretibial area. The exact cause of erythema nodosum is unknown, although it appears to be a hypersensitivity response to a variety of antigenic stimuli. Although the etiology is mostly idiopathic, ruling out an underlying disease is imperative before diagnosing primary erythema nodosum. Erythema nodosum can be the first sign of a systemic disease that is triggered by a large group of processes, such as infections, inflammatory diseases, neoplasia, and/or drugs. The most common identifiable causes are streptococcal infections, primary tuberculosis, sarcoidosis, Behçet disease, inflammatory bowel disease, drugs, and pregnancy. We propose a diagnostic algorithm to optimize the initial work-up, hence initiating prompt and accurate management of the underlying disease. The algorithm includes an initial assessment of core symptoms, diagnostic work-up, differential diagnosis, and recommended therapies. Several treatment options for the erythema nodosum lesions have been previously reported; nevertheless, these options treat the symptoms, but not the triggering cause. Making an accurate diagnosis will allow the physician to treat the underlying cause and determine an optimal therapeutic strategy.
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Affiliation(s)
- Daniela Michelle Pérez-Garza
- Department of Dermatology, Universidad Autonoma de Nuevo Leon, University Hospital "Dr. José Eleuterio González", Avenida Francisco I. Madero y Avenida Gonzalitos S/N, Colonia Mitras Centro, 64460, Monterrey, Nuevo León, Mexico
| | - Sonia Chavez-Alvarez
- Department of Dermatology, Universidad Autonoma de Nuevo Leon, University Hospital "Dr. José Eleuterio González", Avenida Francisco I. Madero y Avenida Gonzalitos S/N, Colonia Mitras Centro, 64460, Monterrey, Nuevo León, Mexico
| | - Jorge Ocampo-Candiani
- Department of Dermatology, Universidad Autonoma de Nuevo Leon, University Hospital "Dr. José Eleuterio González", Avenida Francisco I. Madero y Avenida Gonzalitos S/N, Colonia Mitras Centro, 64460, Monterrey, Nuevo León, Mexico
| | - Minerva Gomez-Flores
- Department of Dermatology, Universidad Autonoma de Nuevo Leon, University Hospital "Dr. José Eleuterio González", Avenida Francisco I. Madero y Avenida Gonzalitos S/N, Colonia Mitras Centro, 64460, Monterrey, Nuevo León, Mexico.
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Nasca MR, Giuffrida G, Micali G. The Influence of Pregnancy on the Clinical Evolution and Prognosis of Pre-Existing Inflammatory and Autoimmune Skin Disorders and Their Management. Dermatology 2020; 237:771-785. [PMID: 32950977 DOI: 10.1159/000509726] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/24/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Although the possible occurrence of typical dermatoses during pregnancy is well recognized, little is known about the influence of pregnancy on the clinical evolution and prognosis of different pre-existing chronic dermatological disorders. SUMMARY In this study a comprehensive search of the available literature and reviews has been undertaken in order to collect and analyze articles reporting pre-existing chronic skin disorders in pregnant women and report current knowledge on their particular clinical and therapeutic aspects.
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Morris JE, Pecci C. Erythema nodosum in a postpartum primigravida: a case report. J OBSTET GYNAECOL 2018; 39:415-416. [PMID: 30422730 DOI: 10.1080/01443615.2018.1491960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Juliana E Morris
- a Department of Family and Community Medicine , University of California San Francisco , San Francisco , CA , USA
| | - Christine Pecci
- a Department of Family and Community Medicine , University of California San Francisco , San Francisco , CA , USA
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Ozbagcivan O, Akarsu S, Avci C, Inci BB, Fetil E. Examination of the Microbial Spectrum in the Etiology of Erythema Nodosum: A Retrospective Descriptive Study. J Immunol Res 2017; 2017:8139591. [PMID: 28634591 PMCID: PMC5467334 DOI: 10.1155/2017/8139591] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/14/2017] [Accepted: 05/04/2017] [Indexed: 12/18/2022] Open
Abstract
Even though infections are the most common cause of erythema nodosum (EN), only certain microorganisms take the great interest such as streptococci in knowledge. Our aim was to examine the frequency and type of infections in EN, to determine the characteristics of patients with an infectious etiology, and to discuss the role of these microbes in EN pathology in the context of their interactions with humans. Charts of 81 patients with EN who were seen between 2003 and 2017 were retrospectively reviewed. Identified etiological factors were classified into three groups: infectious, noninfectious, and idiopathic. While there were no significant demographic and clinical differences between the infectious and idiopathic groups, systemic symptoms (p = 0.034) and the number of EN lesions (p = 0.016) were significantly lower; the mean erythrocyte sedimentation rate was significantly higher (p = 0.049), but the mean aspartate aminotransferase value was significantly lower in the infectious group compared to the noninfectious group (p = 0.019). Besides streptococci, many other microbes, including the ones living on and inside us, were identified in the etiology of EN. There is a need for large-scale prospective studies involving control groups for a better understanding of the microbial immunopathology of EN.
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Affiliation(s)
- Ozlem Ozbagcivan
- Department of Dermatology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Sevgi Akarsu
- Department of Dermatology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Ceylan Avci
- Department of Dermatology, Bilecik State Hospital, Bilecik, Turkey
| | - Burcu Bahar Inci
- Department of Dermatology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Emel Fetil
- Department of Dermatology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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Chowaniec M, Starba A, Wiland P. Erythema nodosum - review of the literature. Reumatologia 2016; 54:79-82. [PMID: 27407284 PMCID: PMC4918048 DOI: 10.5114/reum.2016.60217] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 04/22/2016] [Indexed: 12/30/2022] Open
Abstract
Erythema nodosum is the most common form of panniculitis. It may have many aetiological factors. Erythema nodosum occurs three to five times more often in female patients. It appears as erythematous painful rounded nodules, located most often on the anterior surface of the lower extremities, and may be accompanied by systemic symptoms such as fever, malaise and arthralgia. During diagnosis, oncological vigilance should be maintained, because erythema nodosum may be a paraneoplastic symptom. It requires an interdisciplinary approach and exclusion of many underlying causes.
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Affiliation(s)
- Małgorzata Chowaniec
- Department of Rheumatology and Internal Diseases, University Hospital in Wroclaw, Wroclaw, Poland
| | - Aleksandra Starba
- Department of Rheumatology and Internal Diseases, University Hospital in Wroclaw, Wroclaw, Poland
| | - Piotr Wiland
- Department of Rheumatology and Internal Diseases, University Hospital in Wroclaw, Wroclaw, Poland
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Yang CS, Teeple M, Muglia J, Robinson-Bostom L. Inflammatory and glandular skin disease in pregnancy. Clin Dermatol 2016; 34:335-43. [DOI: 10.1016/j.clindermatol.2016.02.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Unilateral Erythema Nodosum following Norethindrone Acetate, Ethinyl Estradiol, and Ferrous Fumarate Combination Therapy. Case Rep Obstet Gynecol 2016; 2016:5726416. [PMID: 27110414 PMCID: PMC4826688 DOI: 10.1155/2016/5726416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 03/03/2016] [Indexed: 12/04/2022] Open
Abstract
Erythema nodosum is a septal panniculitis that typically presents as symmetric, tender nodules on the anterior aspects of bilateral lower extremities. Nearly half of cases are due to secondary causes, with oral contraceptive pills being the leading pharmaceutical cause. However, to our knowledge, there has yet to be a published association with norethindrone acetate, ethinyl estradiol, and ferrous fumarate. We report our experience with a 30-year-old woman who developed unilateral tender nodules within a month of starting 1 mg norethindrone acetate and 20 mcg ethinyl estradiol daily. Of note, she had previously taken oral contraceptives with the same estrogen agent but different progesterone, without problems. We conclude that systemically triggered erythema nodosum can present with lesions localized to one extremity. When a patient presents with tender, firm nodules, clinicians should consider the possibility of erythema nodosum and its triggers, such as oral contraceptives. Additionally, should a patient on hormonal therapy develop erythema nodosum, changing the progesterone agent may allow the patient to continue similar therapy without developing symptoms.
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Koufakis T, Gabranis I. Erythema nodosum leads to the diagnosis of pulmonary tuberculosis. Pan Afr Med J 2014; 18:291. [PMID: 25469185 PMCID: PMC4247868 DOI: 10.11604/pamj.2014.18.291.5170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 08/10/2014] [Indexed: 11/11/2022] Open
Abstract
Erythema nodosum is a panniculitis which may have various causes, such as drugs, infections, sarcoidosis, inflammatory bowel disease, tuberculosis or can be idiopathic. We here report a case of a woman diagnosed with pulmonary tuberculosis whose first symptom was erythema nodosum. A thorough clinical and laboratory investigation of the patient presenting with erythema nodosum is always required, in order to assess a possible systemic, underlying condition.
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Affiliation(s)
- Theocharis Koufakis
- Department of Internal Medicine, General Hospital of Larissa, Larissa, Greece
| | - Ioannis Gabranis
- Department of Internal Medicine, General Hospital of Larissa, Larissa, Greece
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