Title: A Study on Etiopathology and predictors of Erythema Nodosum in a Tertiary care hospital of West Bengal

Authors: Dr Atanu Chandra, Dr Indranil Sen, Dr Babulal Daulagajao, Dr Saikot Ganai

 DOI:  https://dx.doi.org/10.18535/jmscr/v6i10.19

Abstract

Aim: To study the etiology of Erythema nodosum (EN) and co-morbidities associated with it among a subset of Indian patients, clinical variation between idiopathic and secondary EN and also to assess the factors predictive for the development of EN.

Method: A cross sectional study was done on thirty patients with EN diagnosed on clinical basis. Patients were subjected to clinical examination, laboratory & radiological investigations including histopathology. Etiology of EN & associated co-morbidities were evaluated. Also the clinical variation between idiopathic and secondary EN was assessed.

Result: The frequency of unknown cause(Idiopathic EN) in our study was56.7%.The etiology could be determined in 43.3% of cases:- Streptococcal infection (23.1%), Tuberculosi s(15.4%), Drugs (15.4%), Pregnancy (15.4%), Behcet’s disease (15.4%), Sarcoidosis (7.7%), Inflammatory bowel disease (7.7%). 83.3% of the total patients were female & the mean age was 28.18 years in the idiopathic EN and 27.23 years in secondary EN. Hypothyroidism was significantly associated with idiopathic EN. We found significant differences between the idiopathic & secondary causes regarding history of fever within last 6 weeks, arthritis, cough, chest X ray abnormalities & ASO titre.

Conclusions: Etiological diagnosis was possible in 43.3% of cases. Most common cause was Streptococcal infection. Most of the cases were female. Idiopathic EN was significantly associated with hypothyroidism. Features like history of fever within last 6 weeks, arthritis, cough, chest X ray abnormalities &ASO titre were predictors of secondary EN. We compared our study results with other studies & emphasize the need of a detailed workup for all patients of EN because it’s harbinger of common and treatable conditions.

Keywords: Erythema nodosum, Tuberculosis, Sarcoidosis, Behcet’s disease.

References

  1. Bondi EE, Margolis DJ, Lazarus ZS. Panniculitis. In: Freedberg I, Eisen A, Wolff K, et al, eds. Fitzpatrick's dermatology in general medicine. 5th ed. New York, NY: McGraw-Hill; 1999: 1284-1286.
  2. Requena L, Requena C. Erythema nodosum (review). Dermatol Online J. 2002; 8:4.
  3. Schwartz RA, Nervi SJ. Erythema nodosum: a sign of systemic disease. Am Fam Physician. 2007; 75:695–700. [PubMed]
  4. Blake T, Manahan M, Rodins K. Erythema nodosum – a review of an uncommon panniculitis. Dermatol Online J. 2014; 20:22376. [PubMed]
  5. Acosta KA, Haver MC, Kelly B. Etiology and therapeutic management of erythema nodosum during pregnancy: an update. Am J Clin Dermatol.2013; 14:215–220. [PubMed]
  6. Bohn S, Buchner S, Itin, P. Erythema nodosum: 112 cases. Epidemiology, clinical aspects and histopathology. Swiss Med Weekly. 1997; 127(27-28): 1168-1176. [PMID 9324]
  7. Requena L, SanchezYus E. Erythema nodosum. Dermatol Clin.2008; 26: 425-438. [PMID 18793974]
  8. Cribier B, Caille A, Heid E, Grosshans E.Erythema nodosum and associated diseases. A Study of 129 cases.Int J Dermatol.1998; 37:667–72.
  9. Friedman ES, LaNatra N, Stiller MJ. NSAIDs in dermatologic therapy: review and preview. J Cutan Med Surg. 2002; 6:449-459.[Abstract]
  10. Jørgensen KT, Pedersen BV, Nielsen NM, Jacobsen S, Frisch M. Childbirths and risk of female predominant and other autoimmune diseases in a population-based Danish cohort. J Autoimmun. 2012; 38:J81–7. [PubMed]
  11. Costabel U, Guzman J, Drent M. Diagnostic approach to sarcoidosis. Eur Respir Monograph. 2005; 10:259–260.
  12. Uhl JR, Adamson SC, Vetter EA, Schleck CD, Harmsen WS, Iverson LK, et al. Comparison of LightCycler PCR, rapid antigen immunoassay, and culture for detection of group A streptococci from throat swabs.J Clin Microbiol. 2003; 41:242–9.
  13. Mert A, Ozaras R, Tabak F, Ozturk R. Primary tuberculosis cases presenting with erythema nodosum.J Dermatol. 2004;31:66–8.
  14. Louthrenoo W, Lertprasertsuke N, Kasitanon N, Sukitawut W. Erythema nodosum as a manifestation of HIV infection.Asian Pac J Allergy Immunol. 2002; 20:175–8.
  15. Sanders CJ, Hulsmans RF. Persistent erythema nodosum and asympto-maticCampylobacte r J Am Acad Dermatol. 1991; 24(2 pt 1)285–6.
  16. Bottone EJ.Yersinia enterocolitica: the charisma continues. Clin Microbiol Rev. 1997;10:257–76.
  17. Gupta M, Singh K, Lehl SS, Bhalla M. Recurrent erythema nodosum: a red flag sign of hidden systemic vasculitis. BMJ Case Rep. 2013;2013 doi: 10.1136/bcr-2013-009507. [PMC free article] [PubMed][Cross Ref]
  18. Misago N, Tada Y, Koarada S, Narisawa Y. Erythema nodosum-like lesions in Behçet's disease: a clinicopathological study of 26 cases. Acta Derm Venereol. 2012;92:681–686. [PubMed]
  19. Huang BL, Chandra S, Shih DQ. Skin manifestations of inflammatory bowel disease. Front Physiol. 2012;3:1–6.
  20. Racanelli V, Prete M, Minoia C, et al. Rheumatic disorders as paraneoplastic syndromes. Autoimmun Rev.2008;7:352–358. [PubMed]
  21. Trost L, McDonnell J. Important cutaneous manifestations of inflammatory bowel disease. Postgrad Med J. 2005;81:580-585.[Abstract]
  22. Yang SG, Han KH, Cho KH, Lee AY. Development of erythema nodosum in the course of oestrogen replacement therapy.Br J Dermatol. 1997;137:319–20.
  23. Aydın-Teke T1, Tanır G, Bayhan GI, Metin O, Oz N. Erythema nodosum in children: evaluation of 39 patients. Turk J Pediatr.2014 Mar-Apr;56(2):144-9
  24. Mert A, Ozaras R, Tabak F, Pekmezci S, Demirkesen C, Ozturk R. Erythema nodosum: an experience of 10 years.Scand J Infect Dis. 2004;36:424–7.
  25. Erez A, Horowitz J, Sukenik S. Erythema nodosum in the Negev area - a survey of 50 patients. Isr J Med Sci. 1987; 23(12):1228. [PMID 34407]
  26. García-Porrúa C1, González-Gay MA, Vázquez-Caruncho M, López-Lazaro L, Lueiro M, Fernández ML, Alvarez-Ferreira J, Pujol RM. Erythema nodosum: etiologic and predictive factors in a defined population. Arthritis Rheum.2000 Mar;43(3):584-92
  27. Psychos DN, VoulgarisPV, Skopouli FN, DrosoS AA, Moutsopoulos HM.Erythema nodosum:the underlying condition. Clin Rheumatol 2000:19 212-6.
  28. Whig J, Mahajan V, Kashyap A, Gupta S. Erythema nodosum: atypical presentation of common disease.Lung India 2010; 27: 181-182.
  29. Sarveswari K N, Swamikannu M, Ramakrishnan S. An aetiological analysis of erythema nodosum in a community hospital. Indian J Dermatol Venereol Leprol 2001; 67:287-9
  30. Mert A, Kumbasar H, Ozaras R, et al. Erythema nodosum: an evaluation of 100 cases. Clin Exp Rheumatol. 2007; 25:563–70. [PubMed]
  31. Kakourou T,Drosatou P, Psychou F, Aroni K, Nicholaidou p,.Erythema nodosum in children.J Am acad Dermatol 2011;44:17-21.
  32. Fox MD, Schwartz RA. Erythema nodosum. Am Fam Physician 1992; 46:818-22.

Corresponding Author

Dr Indranil Sen

Address: HB-8/2 Sector-3 Salt Lake Kolkata Pin: 700106, India

Email: This email address is being protected from spambots. You need JavaScript enabled to view it., Phone Number: 8902725184