Erythema induratum of bazin: role of polymerase chain reaction in diagnosis

Cutaneous tuberculosis in Rio de Janeiro, Brazil: description of a series of 75 cases

BACKGROUND

Brazil is one of the highest tuberculosis (TB) burden countries of the world. Cutaneous tuberculosis (CTB) is a rare form of extrapulmonary manifestation of tuberculosis. This study aimed to describe the clinico-evolutive, laboratory and therapeutic aspects of CTB cases among patients from a cohort with TB in Rio de Janeiro, Brazil.

METHODS

Cases of diagnosed CTB with microbiologic confirmation or clinical response to anti-tuberculous treatment associated with positive smear or histopathological findings between the years 2000 and 2016 were selected.

RESULTS

Seventy-five patients with CTB were included, most were women (58.7%) with a median age of 42 years. CTB diagnosis was based on culture in only 42.7% of the cases. Scrofuloderma represented 50.7% of the cases, followed by erythema induratum of Bazin (EIB) (18.7%), tuberculous gumma (13.3%), lupus vulgaris (8%), TB verrucosa cutis (4%), orificial TB (2.7%) and associated forms (2.7%). Other TB presentations were pulmonary (22.7%), mammary (6.6%) and osteoarticular (4%). All patients who completed the treatment (97.3%) had their lesions healed. Only two patients (2.6%) needed to change the therapy due to adverse reactions. Fifty percent of EIB patients presented recurrence.

CONCLUSIONS

These data highlight the diversity of CTB presentations and the importance of the skin to assist in early identification and treatment of TB. More studies are necessary to improve the knowledge on EIB for a better approach towards these patients, mainly in cases of recurrence.

Successful treatment of erythema induratum with topical application of antituberculous drugs: A case report

RATIONALE

Erythema induratum, a chronic recurrent lobular panniculitis with vasculitis, is strongly associated with Mycobacterium tuberculosis infection. The recommended drugs include isoniazid, rifampicin, and pyrazinamide, which are typically administered in combination (orally or intravenously). Till date, there are no reports about topical application of anti-tuberculous (anti-TB) drugs for treatment of erythema induratum.

PATIENT CONCERNS

Herein, we present the case of a 73-year-old woman with recurrent ulceration, scarring and obvious pain in her lower legs.

DIAGNOSES

She was diagnosed of erythema induratum.

INTERVENTIONS

Topical anti-TB treatment (3.75% isoniazid twice a day) was necessitated by the development of severe gastrointestinal upset and significant reduction in platelets after oral treatment with isoniazid and rifampicin.

OUTCOMES

The skin lesions showed improvement at one month and remitted mostly at two months. After 6 months, the skin lesions have subsided and no obvious side effects were observed.

LESSONS

Our experience may help expand the therapeutic regimens for cutaneous tuberculosis, and provide physicians with alternative options for management of tuberculosis.

Primary Tuberculosis Cases Presenting with Erythema Nodosum

Erythema nodosum (EN) is seen only in the primary tuberculosis (TB) form of tuberculous diseases. Among the etiologies of EN, TB is the most frequent disorder in developing countries. We aimed to assess our patients with EN in reference to primary TB. We evaluated 335 patients with the diagnosis of TB during last 20 years; retrospectively 61 (18%) of these cases had pulmonary and 274 (82%) had extrapulmonary TB. Ten (16%) of the pulmonary TB cases were primary. All 10 patients with primary TB presented with EN. Among 50 patients with EN diagnosed and followed during the last 10 years, the etiology was determined in 56%, and primary TB was the most frequent: 20%.

Application of the QuantiFERON®-TB Gold test in erythema induratum

Erythema induratum (EI) was originally described by Ernest Bazin in 1861 as nodular lesions on the legs in association with tuberculosis (TB). A 33-year-old woman was referred to our hospital with tender ulcerative nodules on her legs. Skin biopsies revealed lobular inflammation of the subcutaneous fat with vasculitis. Although conservative treatment was given, the lesions did not improve. Several months later as the lesions persisted, we suspected a TB infection and additional tests were performed. The chest roentgenogram results were normal. The skin biopsies were negative for acid-fast bacilli (AFB). Mycobacterial cultures of the blood and skin were negative. However, the QuantiFERON®-TB Gold test was positive, which led to a diagnosis of latent TB infection being made. The patient was treated with multidrug antituberculosis therapy, which successfully resolved her skin lesions. Therefore, reported herein is the application of the QuantiFERON®-TB Gold test for the confirmation of latent TB infection in EI patients.

Erythema induratum of Bazin associated with Addison's disease: first description

CONTEXT

Erythema induratum of Bazin (EIB) is considered to be a tuberculid reaction and consists of recurrent painful nodules. The differential diagnosis includes diseases like nodular vasculitis, perniosis, polyarteritis nodosa and erythema nodosum.

CASE REPORT

We report the case of a woman with EIB who developed Addison's disease during treatment with anti-tuberculosis drugs with good response to glucocorticoid replacement. The diagnosis was obtained through the clinical picture, positive tuberculin test and positive BCG (bacillus Calmette-Guérin) test on the histological sample. Anti-tuberculosis drugs and glucocorticoid replacement led to disappearance of the signs and symptoms.

CONCLUSIONS

This is the first description of an association between EIB and Addison's disease. It should be borne in mind that tuberculosis is an important etiological factor for Addison's disease.

Erythema induratum of Bazin in an infant after Bacille Calmette-Guerin vaccination

We report the first case of erythema induratum of Bazin (EIB) after Bacille Calmette-Guerin (BCG) vaccination in an infant. The patient developed recurrent multiple erythematous and subcutaneous nodules on his legs 2 months after a BCG vaccination. He had no other symptoms or family history of tuberculosis (TB). Histopathological findings revealed a granulomatous lobular panniculitis. EIB often appears as a chronic, nodular eruptions that frequently occur on the lower legs of females with tuberculin hypersensitivity. To date, only a few cases of infants with EIB have been reported. There have been no clinical reports of EIB after BCG vaccination. Our case suggests that Mycobacterium bovis in the BCG vaccination may have caused EIB.

Erythema induratum of Bazin and renal tuberculosis: report of an association

Erythema induratum of Bazin is a disease that usually affects women, in whom erythematous subcutaneous nodules and plaques appear on the posterior part of the lower extremities, some of which ulcerate. In many countries, tuberculosis is still the main etiologic factor. We report a case of a 40-year-old woman who presented a course of protracted and recurrent episodes over five years of cutaneous lesions on her legs. These tend to involute, but new crops appear at irregular intervals. It was painful, erythematous-violaceous nodules, some of which drained a reddish secretion. The histopathologic features of the lesions demonstrated inflammatory infiltration, with predominance of neutrophils in dermis and hypodermis, necrotizing vasculitis in the arterioles and septal fibrosis. There was no granuloma. The Ziehl-Neelsen stain did not revealed acid-fast bacilli, and the culture of biopsy specimen was negative. The tuberculin skin test was strongly positive (17 mm). The chest X-ray was normal. Few months later she presented adynamia and urinary complaints, such as polacyuria and dysuria. It has been done an urynalysis, which demonstrated acid pH urine, sterile pyuria and microscopic hematuria. It was then raised the diagnostic hypothesis of renal tuberculosis. The urine culture for M. tuberculosis was positive in two out of ten samples. The treatment was instituted with rifampin, isoniazid and pyrazinamide, with complete regression. This case illustrates a clear association between erythema induratum and renal tuberculosis, demonstrated by the remission of the cutaneous lesions after the treatment of the renal tuberculosis.