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erythema nodosum (septal panniculitis)

A skin rash characterized by painful erythematous nodules on the lower extremities. Etiology: 1) generalized infection a) fungal 1] coccidioidomycosis 2] histoplasmosis 3] blastomycosis b) bacterial 1] beta-hemolytic streptococcus* (most common identifiable cause) 2] Yersinia 3] lymphogranuloma venereum 5] Chlamydia psittaci (psittacosis) 6] Bartonella henselae (cat scratch disease) 7] Salmonella 8] Mycobacterial a] leprosy b] primary tuberculosis in children (rare) c) viral: hepatitis B d) parasites 1] helminths 2] protozoa 2) allergic reaction - pharmaceutical agents* - estrogens - oral contraceptives - hormone replacement therapy [5] - penicillins - sulfonamides - aspartame - bromides/iodides 3) sarcoidosis*, Lofgren's syndrome 4) inflammatory bowel disease* a) ulcerative colitis b) Crohn's disease c) frequently a harbinger of active intestinal disease 5) Behcet's syndrome 6) neoplasia 7) pregnancy 8) connective tissue disease a) dermatomyositis b) systemic lupus erythematosus c) scleroderma d) polyarteritis nodosa 9) Sweet syndrome 10) malignancy, lymphoma (rare) [5] 11) idiopathic (40-50%) * most common causes [5] Epidemiology: 1) generally 15-30 years of age, but dependent upon etiology 2) female:male ratio 3:1 Pathology: 1) inflammation of the septae of fat labules [5] 2) neutrophil & lymphocytic infiltration of subcutaneous tissue Clinical manifestations: 1) large erythematous nodules a) sudden onset, transient (days) b) bilateral, but not symmetrically distributed c) occurring in groups d) painful & tender e) generally limited to the legs & knees, seldom above f) non suppurative nodules g) nodules do not ulcerate h) lesions leave area of pigmentation (blue) after resolution of nodule i) nodules 3-20 cm in size, 2-3 cm in size [5] j) nodules located in subcutaneous fat, appreciated best on palpation. k) spontaneous resolution in 4-6 weeks, but course of disorder depends upon etiology l) case presented as faint pink-brown nodules [5] 2) extra-cutaneous manifestations a) malaise b) nausea/vomiting c) abdominal cramps d) arthralgia (most commonly ankles) e) fever f) prodrome of fevers, malaise, arthralgias 1-3 weeks prior to appearance of nodules [16] * images [10,11,12] Laboratory: 1) throat culture for beta-hemolytic streptococcus 2) stool culture for Yersinia 3) serology a) coccidioidomycosis b) histoplasmosis 4) complete blood count (CBC) may show leukocytosis 5) skin biopsy not indicated - histopathology reveals septal panniculitis regardless of etiology Radiology: 1) chest X-ray a) rule out sarcoidosis, tuberculosis, lymphoma, coccidioidomycosis b) hilar adenopathy may be present in the absence of underlying systemic illness Differential diagnosis: - palpable purpura Management: 1) symptomatic, bed rest & compressive bandages 2) non-steroidal anti-inflammatory drugs (NSAIDs) 3) recalcitrant disease may require immunosuppressive agents - oral prednisone when infectious etiology has been excluded 4) treatment of inflammatory bowel disease - if due to inflammatory bowel disease, typically resolves with treatment of the underlying inflammatory bowel disease [5]

Related

erythema

General

skin nodule panniculitis dermatoses of pregnancy

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
  2. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 883
  3. Color Atlas & Synopsis of Clinical Dermatology, Common & Serious Diseases, 3rd ed, Fitzpatrick et al, McGraw Hill, NY, 1997, pg 336-37
  4. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 170
  5. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018
  6. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 303-304
  7. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 95
  8. Requena L, Sanchez Yus E. Erythema nodosum. Semin Cutan Med Surg. 2007 Jun;26(2):114-25. PMID: 17544964
  9. Requena L, Yus ES. Erythema nodosum. Dermatol Clin. 2008 Oct;26(4):425-38, v PMID: 18793974
  10. Hebel JL, James WD (image) Medscape: Erythema Nodosum http://emedicine.medscape.com/article/1081633-overview
  11. DermNet NZ. Erythema nodosum (images) http://www.dermnetnz.org/vascular/erythema-nodosum.html
  12. Rashid RM, Barros BS (images) Hidden Heart Disease: 19 Dermatologic Clues You Should Know. Medscape. June 13, 2017. http://reference.medscape.com/slideshow/hidden-heart-disease-6004452
  13. Chowaniec M, Starba A, Wiland P. Erythema nodosum - review of the literature. Reumatologia. 2016;54(2):79-82. Review. PMID: 27407284 Free PMC Article
  14. Acosta KA, Haver MC, Kelly B. Etiology and therapeutic management of erythema nodosum during pregnancy: an update. Am J Clin Dermatol. 2013 Jun;14(3):215-22. Review. PMID: 23625180
  15. Perez-Garza DM et al. Erythema nodosum: a practical approach and diagnostic algorithm. Am J Clin Dermatol 2021 May; 22:367. PMID: 33683567 PMCID: PMC7938036 Free PMC article
  16. NEJM Knowledge+ Dermatology - Blake T, Manahan M, Rodins K. Erythema nodosum - a review of an uncommon panniculitis. Dermatol Online J. 2014 Apr 16;20(4):22376. PMID: 24746312 Free article. Review.