erythema nodosum (septal panniculitis)
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Introduction
A skin rash characterized by painful erythematous nodules on the lower extremities.
Etiology
- generalized infection
- fungal
- bacterial
- beta-hemolytic streptococcus* (most common identifiable cause)
- Yersinia
- lymphogranuloma venereum
- Chlamydia psittaci (psittacosis)
- Bartonella henselae (cat scratch disease)
- Salmonella
- Mycobacterial
- leprosy
- primary tuberculosis in children (rare)
- viral: hepatitis B
- parasites
- allergic reaction
- pharmaceutical agents*
- sarcoidosis*, Lofgren's syndrome
- inflammatory bowel disease*
- ulcerative colitis
- Crohn's disease
- frequently a harbinger of active intestinal disease
- Behcet's syndrome
- neoplasia
- pregnancy
- connective tissue disease
- Sweet syndrome
- malignancy, lymphoma (rare)[5]
- idiopathic (40-50%)
* most common causes[5]
Epidemiology
- generally 15-30 years of age, but dependent upon etiology
- female:male ratio 3:1
Pathology
- inflammation of the septae of fat labules[5]
- neutrophil & lymphocytic infiltration of subcutaneous tissue
Clinical manifestations
- large erythematous nodules
- sudden onset, transient (days)
- bilateral, but not symmetrically distributed
- occurring in groups
- painful & tender
- generally limited to the legs & knees, seldom above
- non suppurative nodules
- nodules do not ulcerate
- lesions leave area of pigmentation (blue) after resolution of nodule
- nodules 3-20 cm in size, 2-3 cm in size[5]
- nodules located in subcutaneous fat, appreciated best on palpation.
- spontaneous resolution in 4-6 weeks, but course of disorder depends upon etiology
- case presented as faint pink-brown nodules[5]
- extra-cutaneous manifestations
- malaise
- nausea/vomiting
- abdominal cramps
- arthralgia (most commonly ankles)
- fever
- prodrome of fevers, malaise, arthralgias 1-3 weeks prior to appearance of nodules[16]
Laboratory
- throat culture for beta-hemolytic streptococcus
- stool culture for Yersinia
- serology
- complete blood count (CBC) may show leukocytosis
- skin biopsy not indicated
- histopathology reveals septal panniculitis regardless of etiology
Radiology
- chest X-ray
- rule out sarcoidosis, tuberculosis, lymphoma, coccidioidomycosis
- hilar adenopathy may be present in the absence of underlying systemic illness
Differential diagnosis
Management
- symptomatic, bed rest & compressive bandages
- non-steroidal anti-inflammatory drugs (NSAIDs)
- recalcitrant disease may require immunosuppressive agents
- oral prednisone when infectious etiology has been excluded
- treatment of inflammatory bowel disease
- if due to inflammatory bowel disease, typically resolves with treatment of the underlying inflammatory bowel disease[5]
More general terms
Additional terms
References
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
- ↑ DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 883
- ↑ Color Atlas & Synopsis of Clinical Dermatology, Common & Serious Diseases, 3rd ed, Fitzpatrick et al, McGraw Hill, NY, 1997, pg 336-37
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 170
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 303-304
- ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 95
- ↑ Requena L, Sanchez Yus E. Erythema nodosum. Semin Cutan Med Surg. 2007 Jun;26(2):114-25. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17544964
- ↑ Requena L, Yus ES. Erythema nodosum. Dermatol Clin. 2008 Oct;26(4):425-38, v PMID: https://www.ncbi.nlm.nih.gov/pubmed/18793974
- ↑ 10.0 10.1 Hebel JL, James WD (image) Medscape: Erythema Nodosum http://emedicine.medscape.com/article/1081633-overview
- ↑ 11.0 11.1 DermNet NZ. Erythema nodosum (images) http://www.dermnetnz.org/vascular/erythema-nodosum.html
- ↑ 12.0 12.1 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
- ↑ Chowaniec M, Starba A, Wiland P. Erythema nodosum - review of the literature. Reumatologia. 2016;54(2):79-82. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27407284 Free PMC Article
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/23625180
- ↑ Perez-Garza DM et al. Erythema nodosum: a practical approach and diagnostic algorithm. Am J Clin Dermatol 2021 May; 22:367. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33683567 PMCID: PMC7938036 Free PMC article
- ↑ 16.0 16.1 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: https://www.ncbi.nlm.nih.gov/pubmed/24746312 Free article. Review.