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An epidemic of 44 cases of milker's nodules was recorded in the Tampere Central Hospital catchment area in Finland during the autumn of 1974. Exanthema or erythema multiforme-like secondary eruptions were seen in 10 cases. One female patient is reported in detail because of the simultaneous occurrence of erythema nodosum and erythema multiforme. The virological diagnosis was confirmed by electron microscopy.
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The histopathology of erythema nodosum is discussed with reference to the literature and of 19 cases of our clinic. There is a significant vascular involvement especially of the subcutaneous tissue. The veins and arteries are equally affected. The histological picture consists not only of an acute inflammatory process in the subcutaneous tissue, but also of inflammatory cells which area see to a lesser extent in the dermis. In many cases the typical small granulomatous foci of MIESCHER which are considered to be pathognomonic for erythema nodosum do not develop. In the cases which we examined we were not always able to tell from the histological picture how long the erythema nodosum had been present. Multinucleated giant cells which are often found in the septal connective tissue are seen even in relatively acute cases.
Twenty erythema nodosum leprosum (ENL) patients were examined. Coagulation studies were carried out in 13 of them during their active stage and 7 in the latent stage. From these 13 patients, 6 were re-examined when the disease became latent. From these observations a conclusion can be drawn that there are coagulation abnormalities in the majority of ENL patients in the active stage and these abnormalities will return to normal values when the disease becomes latent.
Erythema nodosum is not an uncommon dermatologic entity. Sarcoidosis and streptococcal infection have become the two most common causes, while tuberculosis was the predominant etiology prior to the use of isoniazid. Histoplasmosis and coccidioidomycosis are two important geographic considerations. Laboratory tests should include a PPD test, chest x-ray, throat culture for beta-streptococcus, and ASO titer determination as a minimum. Symptomatic treatment remains unsatisfactory in many cases, although recent success has been reported with oral potassium iodide.
54 cases of erythema nodosum, seen in the Department of Dermatology at the St. Raphael University Hospital, Louvain, were reviewed for their possible aetiology. A search for Yersinia enterocolitica (Y.e.) agglutinins was performed in 21 patients of whom 8 had significant serum antibody titres. These cases are presented and discussed. Gastro-intestinal symptoms, preceding by 2 weeks the erythema nodosum, are strongly suggestive for an aetiologic link with Y.e. Our observations confirm and extend to this part of Europe, the experience of other, mainly Scandinavian, authors.
Erythema nodosum recurred in a woman during each of her four pregnancies and every time she was started on oral contraceptives. The lesions always disappeared in the fifth month of gestation or when contraceptives were withdrawn. Erythema nodosum is mediated by immune mechanisms, and both pregnancy and oral contraceptive use can interfere with the immune system. The concentrations of oestrogen and progesterone or the ratio between them may be critical to the development of erythema nodosum. The observation that the lesions spontaneously resolved in the fifth month of pregnancy supports this hypothesis.
To document association between erythema nodosum and concomitant fungus infection, we studied seven white women seen during a six-year period in our office practice. Five patients are presented. Unilateral erythema nodosum occurred in three patients on the same side as unilateral tinea. Tests with potassium hydroxide (KOH), cultures of nodules on Sabouraud agar and dermatophyte test medium (DTM), skin biopsy, and clinical examination ruled out nodular granulomatous perifolliculitis of Wilson. Lesions simulating erythema nodosum were produced when Trichophyton antigen was injected subcutaneously in the lower legs. All nodose and fungal lesions cleared after griseofulvin therapy. Fungus infection of feet or nails should be considered a possible cause of erythema nodosum when no other cause is apparent.
Four cases of erythema nodosum associated with pregnancy are reported and the literature reviewed. Erythema nodosum in pregnancy is a self-limited condition requiring minimal supportive treatment. No adverse effects upon pregnancy course or fetal outcome were noted. It is suggested that pregnancy may serve as an etiological basis for the disease.
Histochemical study of fat in the adipocytes of the subcutaneous adipose tissue in 12 patients with erythema nodosum revealed an upset balance of the oxidation process in fat and accumulation of free peroxide and aldehyde groups. The imbalance in the oxidation processes in the adipocytes in the areas of hemorrhages is apparently associated with haemin catalysis. The accumulation of incomplete oxidation products in lesions is believed to be a local process caused by pathological changes in the blood vessels. The toxicity of the products of peroxide oxidation should be taken into consideration in treating patients with erythema nodosum.
The author records a case of ossifying periostitis of the tibia apparently due to erythema nodosum. This does not appear to have been recorded previously. The histology, aetiology and differential diagnosis are discussed. The mechanism is probably one of direct spread from skin to periosteum.
Twenty-two children aged from 3 years 6 months to 12 years with erythema nodosum (EN) were grouped according to aetiology into streptococcal, tuberculous, and those whose aetiology was undetermined. Serum IgE levels were determined in all by the radioimmunosorbent technique. Levels were higher (mean value 991 units/ml) in streptococcal EN than in those of the other two groups (mean value 68 units/ml and 97 units/ml, respectively) and healthy age-matched controls (mean value 60 units/ml). Increase of IgE levels in individual cases of streptococcal EN did not correlate with severity of the clinical manifestations characteristic of that group.
Twenty-four of twenty-eight patients with erythema nodosum and sixteen of seventeen patients with nodular vasculitis responded to treatment with potassium iodide. Relief of symptoms occurred within 2 days. The average duration of treatment was 3 weeks and the lesions took an average of 2 weeks to resolve. The possible mode of action of potassium iodide is discussed and an immunosuppressive effect mediated by heparin is suggested.
An illness due to a leptospiral infection in a boy aged 12 years is described which, in addition to presenting with severe fever, malaise, and aseptic meningitis, showed the rare features of severe bradycardia and erythema nodosum.
Two patients with sudden onset of myelopathy associated with Systemic Lupus Erythematosus (Erythema Nodosum) are described. Pertinent literature is extensively reviewed and these two new patients are added to previously reported 26 patients.
Polymorphonuclear leukocyte motility, both in vivo and in vitro, and reduction of Nitro Blue Tetrazolium was studied in tuberculoid and lepromatous leprosy patients and a group of lepromatous patients with erythema nodosum leprosum (ENL). A profound defect in random migration, chemotaxis, and chemokinesis was found in lepromatous patients with and without complicating ENL, and marked depletion of skin window migration confirmed these in vitro findings. Tuberculoid patients exhibited a mild defect in polymorphonuclear leukocyte motility. Serum inhibitors of normal polymorphonuclear leukocyte chemotaxis were found in all types of leprosy, but sera from lepromatous and ENL patients were most inhibitory. Resting levels of Nitro Blue Tetrazolium reduction were normal in all three groups. Reconstitution of polymorphonuclear leukocyte cells from normal and ENL patients with ENL serum, however, showed increased Nitro Blue Tetrazolium reduction well above the normal range, whereas reconstitution with normal, lepromatous, and tuberculoid sera failed to increase Nitro Blue Tetrazolium reduction above the normal values.