Erythema nodosum

Erythema induratum of Bazin

BACKGROUND

There has been a long controversy about the tuberculous cause of erythema induratum, a chronic form of nodular vasculitis.

METHOD

We investigated clinical, histopathologic, and immunohistochemical features of patients with erythema induratum who showed positive tuberculin hypersensitivity reactions or had associated active tuberculosis.

RESULTS

The ages of the 32 patients (M 7: W 25) ranged from 13 to 66 years (mean 36.6 years). All patients displayed recurrent crops of tender, painful, violaceous nodules or plaques. Most lesions presented on the legs, but they also occurred on thighs, feet, buttocks, and forearms. The skin lesions evolved for several weeks and healed with scarring and residual pigmentation. Twenty-two patients were treated with isoniazid alone and the remaining 10 patients received combinations of antituberculous drugs. Relapses were encountered in four patients who received isoniazid alone or stopped the medication against medical advice. In most biopsies, histologic examination revealed lobular or septolobular panniculitis with varying combinations of granulomatous inflammation, primary vasculitis, and necrosis. Immunohistochemical labeling revealed a preponderance of T lymphocytes, monocyte-macrophages, and Langerhans' cells, indicative of a type IV hypersensitivity reaction.

CONCLUSION

Erythema induratum of Bazin has distinct clinical, histopathologic, and immunohistochemical features. Erythema induratum of Bazin should be considered as a separate entity of nodular vasculitis caused by latent foci of tuberculous infection.

Familial erythema nodosum

Erythema nodosum (EN) is a hypersensitivity reaction associated with many diseases. We describe a family in which 4 sisters had acute or recurrent EN. HLA typing showed a common haplotype in the affected members of the family. A review of familial EN and HLA distribution in EN is presented.

Hyperpigmentation, neutrophilic alveolitis, and erythema nodosum resulting from minocycline

Hyperpigmentation, pulmonary infiltration, and erythema nodosum occurred in a patient receiving long-term minocycline therapy. Bronchoalveolar lavage revealed both a neutrophilic and an eosinophilic alveolitis. The pulmonary and systemic symptoms promptly resolved after discontinuation of minocycline.

Arthritis associated with inflammatory bowel disease in children. Relationship of joint disease to activity and severity of bowel lesion

The records of 102 children with inflammatory bowel disease (44 with ulcerative colitis, 58 with Crohn's disease) were reviewed for evidence of joint disease unassociated with erythema nodosum. Thirteen children had arthritis, four had ulcerative colitis, and nine had Crohn's disease. Arthritis tended to be pauciarticular; ankles, knees, elbows and hips were most commonly affected. In three patients arthritis preceded bowel symptoms, in two the onset of arthritis and bowel disease was concurrent, and in eight arthritis appeared after the onset of bowel symptoms. The relationship between arthritis and specific features reflecting activity and severity of the bowel disease was examined in detail. Twenty-one attacks of arthritis, ranging in duration from two days to 12 weeks (mean, 31 days) were documented. Thirteen attacks occurred when the bowel disease was symptomatic; nine occurred within one month of a flare of the bowel disease. Most exacerbations of bowel disease in patients who had arthritis were unaccompanied by joint complaints. None of the features reflecting activity or severity of the bowel disease was more common in patients with arthritis than in those without arthritis.

Erythema nodosum following typhoid vaccination

Erythema nodosum has recently been recognised in association with salmonella infection (1). We report a case of classical erythema nodosum which developed following a typhoid vaccination.

Musculoskeletal syndromes associated with malignancy

Evidence has been presented supporting a causal relationship between malignancies and musculoskeletal syndromes. This discussion has dealt primarily with lesser known relationships, more common associations such as hypertrophic osteoarthropathy and dermatomyositis being reviewed elsewhere. The ones discussed herein closely mimic primary connective tissue diseases and offer an insight into the study of the pathogenesis of these primary diseases. In view of the natural history of malignant disease, the hope for such patients arises from the physicians early diagnosis and treatment of the underlying malignancy. Early diagnosis and treatment may in turn be entirely dependent on the physician's awareness of a musculoskeletal syndrome being the presenting feature of an otherwise occult neoplasm. Several connective tissue syndromes appear to predispose to the development of malignancy, and increasing evidence suggests that this development of malignancy may be further enhanced by immunosuppressive therapy.

Arthritis with an inflammatory dermatosis resembling Sweet's syndrome. Report of a unique case and review of the literature on arthritis associated with the inflammatory dermatoses

A patient with a unique case of chronic episodic arthritis coincident with flares of acneform, pustular, nodular and ulcerating skin lesions was observed over a five-year period. This patient and a review of the literature on arthritis associated with the inflammatory dermatoses provide evidence which may interrelate several of these nosologically confusing skin conditions, e.g., the family of leukocytoclastic angiitides with the newly posited acute febrile neutrophilic dermatosis of Sweet. Systemic manifestations and a variety of acneform, pustular, nodular and ulcerating cutaneous lesions in the inflammatory dermatoses are best explained by small vessel involvement, with individual syndromes being determined by the type and degree of vascular change. Perivascular neutrophilic infiltration is the unifying histologic feature of these small vessel diseases. Neutrophil infiltration differentiates these entities, and our patient, from the histologically nonspecific inflammations of the skin, e.g., Behcet's disease and pyoderma gangrenosum, which, although capable of causing identically appearing skin lesions, consist predominantly of lymphocytic dermal infiltrates even in the earlier stages. It appears important to recognized these morphologically varied acute inflammatory dermatoses with perivascular neutrophilic infiltration in view of their systemic features and the dramatic efficacy of corticosteroid therapy.