EL ERITEMA NODOSO, BUSCANDO UN ORIGEN  !!!   

Data-Medicos 
Dermagic/Express No. 5-(122) 
30 Junio 2.004 / 30 June 2.004 
 

EDITORIAL ESPANOL
=================

Hola amigos de la red, esta edicion del DERMAGIC de junio esta dedicada al tema ERITEMA NODOSO, BUSCANDO UN ORIGEN, enfermedad dermatologica de multiples causas, que puede afectar niños y adultos de ambos sexos

La razon que me llevo a realizar esta revision fue el haber visto en mi consulta dos mujeres embrazadas afectadas un clasico eritema nodoso en piernas, el unico hallazgo de laboratorio interesante fue que ambas PRESENTABAN TITULOS ELEVADOS DE ASTO (antiestreptolisina O). infeccion estreptoccocica sin ninguna otra manifestacion clinica. Ambos casos se resolvieron con tratamiento de penicilina.

En la revision pude comprobar que el eritema nodoso puede presentarse en embarazo con o sin infeccion estreptococica, y que SON MULTIPLES LAS CAUSAS DEL MISMO, desde idiopatico, condiciones malignas o benignas, hasta una simple infeccion dental.

Los hechos en estas 40 referencias, DONDE PODRAN COMPROBAR QUE muy probablemente detras de un eritema nodoso se encuentra una condicion subyacente ! y a veces EL ORIGEN es mas simple de lo que pensamos.!!!
 

Atentamente

Dr. Jose Lapenta R.
 

EDITORIAL ENGLISH
=================

Hello friends of the net, this edition of the DERMAGIC of June 2.004 is dedicated to the topic ERYTHEMA NODOSUM, LOOKING FOR AN ORIGIN,  dermatologic disease of multiple causes, that can affect children and adults of both sexes

The reason that I take myself to carry out this review was having seen in my consultation two pregnant women affected with a classic erythema nodosum in legs, the only interesting laboratory discovery was that both PRESENTED HIGH TITLES of ASO (antistreptolysin O):  streptococcal infection without any other clinical manifestation. Both cases were solved with treatment of penicillin.

In the review I could check that the erythema nodosum can be presented in pregnancy with or without streptococcal infection, and that they are MULTIPLE THE CAUSES OF THE SAME one, from idiopathic, malignant or benign condition, until a simple dental infection.

The facts in these 40 references, WHERE you can CHECK THAT very probably behind an ERYTHMA NODOSUM is an underlying condition! and it is sometimes THE ORIGIN but simple of what we think. !!!
 

Sincerely

Dr. José Lapenta R.

=====================================================
REFERENCIAS BIBLIOGRAFICAS / BIBLIOGRAPHICAL REFERENCES
======================================================
1.) Erythema nodosum, estrogens, and pregnancy.
2.) [Erythema nodosum and pregnancy. Report of a case]
3.) Erythema nodosum associated with pregnancy. Case reports.
4.) Long-term follow-up of erythema nodosum.
5.) Conditions currently associated with erythema nodosum in Swiss children.
6.) [Erythema nodosum. Review of 68 cases]
7-) [Erythema nodosum and pregnancy]
8.) [Erythema nodosum: 112 cases. Epidemiology, clinical aspects and
histopathology]
9.) Erythema nodosum: the underlying conditions.
10.) Etiology of erythema nodosum.
11.) Erythema nodosum in Israeli children.
12.) [Erythema nodosum: a study of 160 cases]
13.) [Erythema nodosum in the clinical picture of internal diseases]
14.) Skin manifestations of tularemia: a study of 88 cases in northern Finland during
16 years (1967-1983).
15.) Erythema nodosum in pregnant patients with coccidioidomycosis.
16.) Erythema nodosum: prospective study of 32 cases.
17.) Risk factors for erythema nodosum leprosum.
18.) Erythema nodosum in children: a prospective study.
19.) Erythema nodosum as a manifestation of HIV infection.
20.) Erythema nodosum: etiologic and predictive factors in a defined population.
21.) [Erythema nodosum in sarcoidosis patients]
22.) [Hairy cell leukemia associated with tuberculosis, disclosed by erythema
nodosum]
23.) [Erythema nodosum in Chlamydia pneumoniae infection]
24.) [Sweet syndrome and erythema nodosum in ulcerative colitis, refractory to
steroids: successful treatment with tacrolimus]
25.) Erythema nodosum associated with antiphospholipid antibodies: a report of
three cases.
26.) Potassium iodide in the treatment of erythema nodosum and nodular vasculitis.
27.) Primary tuberculosis cases presenting with erythema nodosum.
28.) [Ulcerative colitis concomitant with pyoderma gangrenosum and erythema
nodosum--presentation of two cases]
29.) Erythema nodosum heralding recurrent Hodgkin's disease.
30.) Erythema nodosum of dental origin.
31. Erythema nodosum and giardia intestinalis.
32.) Erythema nodosum following typhoid vaccination.
33.) Salmonella gastroenteritis--another cause of erythema nodosum.
34.) Onset of erythema nodosum during pregnancy: a case report.
35.) Erythema nodosum associated with acute cytomegalovirus mononucleosis in an
adult.
36.) [Erythema nodosum in Campylobacter jejuni colitis]
37.) Granulomatous mastitis--a rare cause of erythema nodosum.
38.) Erythema nodosum in the Negev area--a survey of 50 patients.
39.) Immunoglobulin E in erythema nodosum.
40.) [Erythema nodosum association with malignant lymphoma]
==============================================
==============================================
1.) Erythema nodosum, estrogens, and pregnancy.
==============================================
Arch Dermatol. 1980 May;116(5):557-8.

Salvatore MA, Lynch PJ.

During the past ten years we have seen two or more episodes of erythema
nodosum develop in five patients in association with either pregnancy or the
ingestion of female hormones. No alternative causes of erythema nodosum were
found in these patients. The occurrence of erythema nodosum in association with
hormonal change suggests that female hormones can, under some circumstances, be
directly responsible

==============================================
2.) [Erythema nodosum and pregnancy. Report of a case]
==============================================
Ginecol Obstet Mex. 1991 Jun;59:181-3.

[Article in Spanish]

Rosales Estrada G, Smith Alpizar R, Braham Velasco J.

Hospital de Gineco Obstetricia, Dr. Emilio Chuayffet CH, Toluca, Mexico.

Erythema nodosum is a rare disease, it appears frequently in association with
infectious disease and with some drugs administration. A case associated with
pregnancy is presented. The importance of hormonal behavior in its genesis, is
considered. We conclude that the transitional hormone state in women is a very
important factor in it's appearance. Estrogens play an important roll in the
immunological response.

==============================================
3.) Erythema nodosum associated with pregnancy. Case reports.
==============================================
Eur J Obstet Gynecol Reprod Biol. 1979 Dec;9(6):399-401.

Langer R, Bukovsky I, Lipshitz I, Ariely S, Caspi E.

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.

==============================================
4.) Long-term follow-up of erythema nodosum.
==============================================
J Med Assoc Thai. 2003 Dec;86(12):1095-100.

Tantisirin O, Puavilai S.

Division of Dermatology, Department of Medicine, Faculty of Medicine,
Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.

One hundred and fifty-four patients with erythema nodosum who attended the skin
clinic at Ramathibodi Hospital from January 1990 to December 2000 were
evaluated retrospectively with regard to the etiology of erythema nodosum. Of 49
patients who attended the skin clinic during that time 26 returned for reevaluation.
Of the 154 patients, their ages ranged from 10-72 years old; 138 were females, 16
were males. The most common cause of erythema nodosum was tuberculosis (12.
3%). Upper respiratory tract infection was found in 3.9 per cent. Other causes
included Behcet's disease, sytemic lupus erythematous, drugs, pregnancy, chronic
myeloid leukemia, leprosy, Reiter's syndrome and inflammatory bowel disease. Of
the 26 patients who returned for reevaluation, pulmonary tuberculosis was identified
in only one patient who had developed erythema nodosum 16 months earlier. In
conclusion, it was found that tuberculosis is still a predominant cause of erythema
nodosum among Thai patients.

==============================================
5.) Conditions currently associated with erythema nodosum in Swiss children.
==============================================
Eur J Pediatr. 1997 Nov;156(11):851-3.

Hassink RI, Pasquinelli-Egli CE, Jacomella V, Laux-End R, Bianchetti MG.

Kinderklinik, Inselspital, Bern, Switzerland.

A review was made of the 36 paediatric patients in whom the diagnosis of erythema
nodosum had been established between 1977 and 1996 at the Department of
Paediatrics, University of Bern, Switzerland. Infectious diseases were associated
with erythema nodosum in 20 (including 10 streptococcal infections) and non-
infectious inflammatory diseases in 8 patients. None of the 36 patients had
tuberculosis or had been exposed to sulphonamides, phenytoin or hormonal
contraceptives. There were eight patients in whom either the associated disease
was not diagnosed, or there was no other disease. Conclusion: Most cases of
erythema nodosum are nowadays caused by non-mycobacterial infectious diseases
or by non-infectious inflammatory diseases.

==============================================
6.) [Erythema nodosum. Review of 68 cases]
==============================================
Rev Clin Esp. 1983 Dec 31;171(6):405-8.

[Article in Spanish]

More Monreal J, Rodriguez de la Serna A.

PIP: A study was conducted of 68 patients suffering from erythema nodosum (EN)
with special emphasis on the etiological and immunological aspects. 60 of this group
were women (88%). Etiological factors were discovered in 37 cases (54%);
streptococcia in 16, anovulatory drugs in 4, both factors in 3, tuberculosis in 5,
sarcoidosis in 5, Crohn's disease in 1, ulcerous colitis in 1, Yersinia in 1, and
Salmonella entetitis in 1. In the other 31 cases, there were elements of dubious
etiology in 25 (37%); streptococcia in 13, tuberculosis in 10, and pregnancy in 2. In
6 cases (9%), no factor was detected which could be linked with the EN. In the
cases associated with sarcoidosis, the proportion of males was significantly higher
(P0.01). At the same time, polymorphous erythema was detected in 4 cases and
rheumatic fever in 1 cases. The immunological parameters revealed no significant or
specific changes (circulating immunocompleses, ANA complement,
immunoglobulins, and Ag HBs). The authors discuss these results and compare
them with other series, and stress the importance of EN in the diagnosis of
associated, general illnesses. (author's modified)

==============================================
7-) [Erythema nodosum and pregnancy]
==============================================
Rev Med Interne. 1997;18(2):172.

[Article in French]

Mathieu E, Fain O, Bon-Marty M, Feton N, Sitbon M, Thomas M.

Publication Types:
Letter
==============================================


==============================================
8.) [Erythema nodosum: 112 cases. Epidemiology, clinical aspects and
histopathology]
==============================================
Schweiz Med Wochenschr. 1997 Jul 8;127(27-28):1168-76.


Comment in:
Schweiz Med Wochenschr. 1998 Jan 17;128(3):85.

[Article in German]

Bohn S, Buchner S, Itin P.

Dermatologische Universitatsklinik Basel.

In a retrospective study we analyzed the cases of 112 patients with erythema
nodosum treated during the period 1983-1993 in the Department of Dermatology,
University Hospital of Basel, Switzerland. The aim of the study was to investigate
the epidemiology, incidence of different etiologies, relevance of laboratory
investigations and the histopathologic features in our patients, 83% of whom were
females. The peak incidence occurred between the ages of 18 and 34 years. The
commonest cause of erythema nodosum was infection. Other etiologic factors were
adverse drug reactions, sarcoidosis, Crohn's disease, non-Hodgkin lymphoma,
pregnancy, discoid lupus erythematosus, Sharp syndrome and aspartame. Only
47% of patients showed the classic bilateral distribution of the nodes on the
extensor surface of the lower extremities. 77% of infection-induced erythema
nodosum healed after 7 weeks, the longest course being 18 weeks. In contrast,
30% of idiopathic erythema nodosum lasted more than 6 months. Patients in whom
erythema nodosum was associated with non-Hodgkin lymphoma had an extremely
protracted course. Erythema nodosum associated with non-Hodgkin lymphoma
may precede the diagnosis of lymphoma by months. In 4 cases erythema nodosum
was the initial sign of sarcoidosis. In 30% of biopsies we found single vessels with
leukocytoclastic vasculitis. The histologic pattern failed to provide etiologic pointers


==============================================
9.) Erythema nodosum: the underlying conditions.
==============================================
Clin Rheumatol. 2000;19(3):212-6.

Psychos DN, Voulgari PV, Skopouli FN, Drosos AA, Moutsopoulos HM.

Department of Internal Medicine, Medical School, University of Ioannina, Greece.

Erythema nodosum (EN) is a cutaneous reaction consisting of inflammatory, tender
nodular lesions and is associated with a wide variety of disease processes. The aim
of our study was to investigate the frequency of different aetiologies of EN. One
hundred and thirty-two EN patients were investigated in a prospective study during
the period 1984-1990. The evaluation of all patients began with a medical and
family history and completed with a thorough physical examination and detailed
laboratory and immunological work-up. In addition, various diagnostic procedures
were performed where and when indicated. One hundred and ten patients (83%)
were women. Their mean age was 41.0+/-14.0 years, range 18-79 years. In 35%
the cause of EN was not found. Sarcoidosis was revealed in 28% of the patients,
infections in 17.3% and tuberculosis in 1.5%. Other aetiologic factors were
Adamantiadis-Behcet's syndrome (3.8%), pregnancy (6%), oral contraceptives (3
.8%) and other drugs (3.8%). The aetiology of EN was not found in 35% of the
patients. Sarcoidosis and infections were frequent causes of EN, whereas
autoimmune rheumatic diseases rarely cause EN.

==============================================
10.) Etiology of erythema nodosum.
==============================================
J Med Assoc Thai. 1995 Feb;78(2):72-5.

Puavilai S, Sakuntabhai A, Sriprachaya-Anunt S, Rajatanavin N, Charuwichitratana
S.

Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, Bangkok, Thailand.

One hundred patients with biopsy-proven erythema nodosum were studied at
Ramathibodi Hospital from 1982 to 1992 to find out the etiology of this disease.
Eighty-eight were females while twelve were males, with an age range from 6 to 72
years old (mean, 31 years old). Abnormal laboratory findings in these patients
included elevation of erythrocyte sedimentation rate (76.9%), increase anti-
streptolysin-O titer (10.7%), abnormal chest roentgenogram (16.7%), positive
tuberculin test (50%). The cause of erythema nodosum is still unknown in a large
group of patients, and it was found only in twenty-eight patients (28%). Twelve
patients had tuberculosis, seven had history of antibiotic administration, six probably
had streptococcal infection and the other three had Behcet's disease.


==============================================
11.) Erythema nodosum in Israeli children.
==============================================
Isr Med Assoc J. 2000 Feb;2(2):145-6.

Garty BZ, Poznanski O.

Department of Pediatrics B, Schneider Children's Medical Center of Israel, Petah
Tiqva, Israel. [email protected]

BACKGROUND: Erythema nodosum, although uncommon in children, is the most
frequent form of panniculitis in pediatrics. EN has been associated with various
infections and chronic inflammations, and its course varies with age, gender, and
racial and geographic factors. There is no information on EN in Israeli children.
OBJECTIVES: To examine the clinical course of EN and the conditions with which
it is associated in Israeli children. METHODS: We conducted a retrospective study
of 24 children with a diagnosis of EN who presented at our Center over a 10 year
period (1989-98). RESULTS: EN was more frequent in females than males (ratio
2:1) due to a cluster of adolescent girls. The mean duration of the skin manifestation
was 18 days. The course was benign in all patients. Streptococcal infection was the
most common cause (25%), followed by Epstein-Barr virus infection (18%) and
inflammatory bowel disease (13%). In one-third of cases, no specific cause could
be identified. Tuberculosis, an important cause of EN in the past, was not found in
our patients. CONCLUSIONS: Most cases of EN in Israeli children are related to
streptococcal and EBV infections or to chronic inflammatory conditions. Despite
the increase in tuberculosis morbidity in Israel during recent years, we found no
association of EN and tuberculosis in our study.

==============================================
12.) [Erythema nodosum: a study of 160 cases]
==============================================
Med Clin (Barc). 1991 Feb 9;96(5):169-72.

[Article in Spanish]

Atanes A, Gomez N, Aspe B, de Toro J, Grana J, Sanchez JM, Galdo F.

Unidad de Reumatologia, Hospital Juan Canalejo, La Coruna.

We have evaluated 160 patients diagnosed of erythema nodosum (EN) on the basis
of clinical and/or histopathological criteria to assess their etiology and their major
epidemiological, clinical and laboratory features in our area. Mean age was 37.5
years and 86% of patients were females. The etiology could be determined in 67.
5% of cases: sarcoidosis (20.6%), drugs (18%), streptococcal infection (16.3%),
tuberculosis (6.3%), pregnancy (1.9%), Crohn's disease (1.3%), Behcet's disease
(1.3%), lymphoma (0.6%), adenocarcinoma (0.6%), and toxoplasmosis (0.6%).
32.5% of cases were idiopathic. We found significant differences between the
different etiological factors regarding mean age, fever, joint disease, ESR,
leukocytosis and serum proteins. We compare our results with those from other
series and we emphasize the need for a systematic workup in all patients with EN
to facilitate their etiological diagnosis.


==============================================
13.) [Erythema nodosum in the clinical picture of internal diseases]
==============================================
Ter Arkh. 1986;58(6):36-9.

[Article in Russian]

Tareev EM, Kornev BM, Moiseev SV.

A study of 64 patients with erythema nodosum (EN), including 53 females, showed
sarcoidosis diagnosed in 65% of the cases to be the principal cause of EN. It was
followed by drug disease (10%), tuberculosis (3%), pregnancy or labor (5%),
tumors (3%) and other underlying diseases (Behcet's diseases, streptococcal
infection, histoplasmosis, nonspecific aorto-arteritis, chronic active hepatitis). The
cause of EN could not be identified in 5% of patients only. Two or three possible
etiologic factors were identified in 17%. Sarcoidosis combined with EN regressed
without treatment in 82% of cases. Corticosteroid therapy was only given in cases
of pulmonary lesion or other systemic manifestations. Purposeful investigation is
believed to be capable of establishing etiology of EN in virtually all cases.

==============================================
14.) Skin manifestations of tularemia: a study of 88 cases in northern Finland during
16 years (1967-1983).
==============================================
Acta Derm Venereol. 1984;64(6):513-6.

Syrjala H, Karvonen J, Salminen A.

88 tularemia patients with secondary skin manifestations seen in northern Finland
during 1967-1983 are described in this paper. Tularemia was ulceroglandular in
57% and pulmonary in 27% of the patients. 68% of the patients were women. The
most common secondary skin manifestation was papular or vesicopapular eruption
which was seen in 42% of the patients. Erythema nodosum either alone or in
combination with some other skin eruption was encountered in 28% and erythema
multiforme in 9% of the patients. Erythema nodosum was seen more often in
patients with pulmonary tularemia than in other types of the disease (p less than 0.
01). The clinical pictures of erythema nodosum and erythema multiforme caused by
tularemia greatly resembled those caused by Yersinia. Tularemia should be
remembered as one possible triggering factor of erythema nodosum and erythema
multiforme.

==============================================
15.) Erythema nodosum in pregnant patients with coccidioidomycosis.
==============================================
Clin Infect Dis. 1998 Nov;27(5):1201-3.

Arsura EL, Kilgore WB, Ratnayake SN.

Department of Internal Medicine, UCLA-Kern Medical Center, Bakersfield,
California, USA.

Pregnant patients with coccidioidomycosis develop dissemination and serious
disease more frequently than do the general population. To assist in prognosis and
management, we analyzed the significance of erythema nodosum in pregnant
patients with coccidioidomycosis. Sixty-one pregnant patients (mean age +/- SD,
26.4 +/- 6.3 years) were evaluated. Seventy percent of the patients were Hispanic;
15%, African American; 13%, Caucasian; and 2%, unknown race. Of the 30
patients (49%) who developed erythema nodosum, 0 had disseminated disease (P
= .001), 1 (3%) with pulmonary involvement required therapy for > 1 year, and 29
(97%) recovered (P = .0008). Of the 31 patients (51%) without erythema
nodosum, 11 (35%) had disseminated disease, 12 (39%) required therapy for > 1
year, 17 (55%) recovered, 1 (3%) died, and 1 (3%) had an outcome that was
unknown. Erythema nodosum appears to be a salient marker of a positive outcome
for pregnant patients, more so than for the general population.

==============================================
16.) Erythema nodosum: prospective study of 32 cases.
==============================================
Rev Inst Med Trop Sao Paulo. 1994 Nov-Dec;36(6):507-13.

Fernandes NC, Maceira J, Muniz Mde M.

Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Hospital
Universitario Clementino Fraga Filho, Brasil.

The results of 32 cases studied lead us to the conclusion that erythema nodosum's
investigation routine is very important, once in our retrospective study, the
percentage of cases of unknown etiology was 69.4%, and in this prospective study
it is 21.8%. In 10 cases (31.2%), more than one causing agent was suspected.
Infections (bacterial, helminthic, fungal, by protozoa) were diagnosed in 26 cases,
streptococcal infection having predominated (12 cases). Drugs-dipirone, aspirin,
anovulatory--were suspected as causing agents in 13 cases. The association of
erythema nodosum and histoplasmosis capsulata is described for the first time in
Brazil. We consider erythema nodosum to be a complex syndrome which should be
regarded as a manifestation of underlying diseases. The fact that all 32 subjects
were women, 26 of them during menacme, suggests that particular hormonal media
may favor the action of various processes (infections and drugs), precipitating
erythema nodosum's clinical picture.

==============================================
17.) Risk factors for erythema nodosum leprosum.
==============================================
Int J Lepr Other Mycobact Dis. 1999 Sep;67(3):270-8.

Manandhar R, LeMaster JW, Roche PW.

Mycobacterial Research Laboratory, Anandaban Leprosy Hospital, Kathmandu,
Nepal.

A retrospective study of new borderline lepromatous and lepromatous patients
reporting for multidrug therapy (MDT) for leprosy at the Anandaban Leprosy
Hospital, Kathmandu, Nepal, over an 8-year period was conducted to determine
the prevalence of erythema nodosum leprosum (ENL), the time and frequency of
reactions, and clinical and laboratory parameters associated with ENL. An overall
prevalence of ENL in this cohort of 19% was found. One third of these reactions
occurred in patients before MDT was given, one third in the first 6 months and one
third after 6 months of treatment. Nearly 1 in 10 of the ENL reactions occurred in
patients who had completed 2 years of MDT; 45% of patients with ENL had more
than one episode. Data collected at the patients' first presentation was used to
identify four major risk factors. Patients with lepromatous disease, skin infiltration or
a bacterial index (BI) of > 4+ were at significantly increased risk. Patients older
than 40 were at significantly decreased risk of ENL. There was a linear relationship
in the risk of ENL with an increasing BI and an inverse relationship to increasing
age. These observations should enable clinicians to recognize patients at first
presentation who will be likely to develop ENL.


==============================================
18.) Erythema nodosum in children: a prospective study.
==============================================
J Am Acad Dermatol. 2001 Jan;44(1):17-21.

Kakourou T, Drosatou P, Psychou F, Aroni K, Nicolaidou P.

First Department of Pediatrics, and the Department of Pathology, Athens
University, Greece.

BACKGROUND: The studies of series of children with erythema nodosum (EN)
are limited and mostly retrospective. OBJECTIVE: We evaluated the
epidemiology, etiology, clinical manifestations, course, and prognosis of EN in
children. METHODS: Thirty-five children with EN (17 boys, 18 girls; mean age, 8
.79 years) have been studied. Four excluded children proved, on biopsy, to have
leukocytoclastic vasculitis (n = 3) or eosinophilic cellulitis (n = 1). RESULTS: In 27
of the 35 children (77%), the etiology of EN was established by laboratory
investigations. In 25 children the causative factor of EN was an infectious agent (
including beta-hemolytic streptococcus [n = 17], and Mycobacterium tuberculosis
[n = 2]), whereas in 2 patients, EN was associated with Crohn's disease in one and
Hodgkin's disease in the other. In 8 of the 35 children (23%) the etiology of EN
remained undetermined. The mean duration of the rash was 11.5 days. Recurrences
were noted in only 2 children (1 episode in 1 child and 3 episodes in the other).
CONCLUSION: Currently the most common provoking agent of EN in children in
Greece is beta-hemolytic streptococcus. However, Mycobacterium tuberculosis
should still be considered as a cause of the disorder. Also, the course of EN is
benign and recurrences are exceptional.

==============================================
19.) Erythema nodosum as a manifestation of HIV infection.
==============================================
Asian Pac J Allergy Immunol. 2002 Sep;20(3):175-8.

Louthrenoo W, Lertprasertsuke N, Kasitanon N, Sukitawut W.

Division of Rheumatology, Department of Medicine, Faculty of Medicine, Chiang
Mai University, Chiang Mai 50200, Thailand.

Various musculoskeletal syndromes have been well described in patients infected
with the human immunodeficiency virus (HIV). Surprisingly, erythema nodosum, an
inflammation of the adipose tissue of the skin, has rarely been described. We report
a 24-year-old known case of HIV infection, who developed fever and multiple
tender subcutaneous nodules that were proven to be erythema nodosum. The
patient also had polymyositis. She responded well to a high dose of corticosteroids.
Erythema nodosum should be listed as possible the rheumatic manifestation of HIV
infection.


==============================================
20.) Erythema nodosum: etiologic and predictive factors in a defined population.
==============================================
Arthritis Rheum. 2000 Mar;43(3):584-92. Related Articles, Links

Erratum in:
Arthritis Rheum 2000 May;43(5):1061.

Garcia-Porrua C, Gonzalez-Gay MA, Vazquez-Caruncho M, Lopez-Lazaro L,
Lueiro M, Fernandez ML, Alvarez-Ferreira J, Pujol RM.

Hospital Xeral-Calde, Lugo, Spain.

OBJECTIVE: To examine the frequency and features of erythema nodosum (EN),
establish disease associations, and identify the optimal set of predictors for the
occurrence of secondary EN. METHODS: We performed a retrospective study of
an unselected population of patients 14 years and older with biopsy-proven EN
diagnosed at a referral hospital between 1988 and 1997. Patients were classified as
having either idiopathic EN or EN secondary to other diseases if the skin nodules
occurred in the context of a well-defined disease, or if there was a precipitating
event in close temporal proximity to the onset of EN. RESULTS: One hundred six
patients (82 women) were diagnosed as having biopsy-proven EN. At the time of
diagnosis, no precipitating events or underlying diseases were identified in 36.8% of
patients. Sarcoidosis and nonstreptococcal upper respiratory tract infections (URI)
were the most common conditions associated with secondary EN. Only 1 of 35
patients with an initial diagnosis of idiopathic EN and a followup of at least 1 year
was finally diagnosed as having secondary EN. The best predictive model of
secondary EN included an abnormal results on a chest radiograph, a previous
history of nonstreptococcal URI, and a significant change in antistreptolysin O (
ASO) titer in 2 consecutive determinations performed in a 2-4-week interval. Also,
the presence of peripheral synovitis, a positive tuberculin skin test, and a history of
diarrhea suggested the presence of secondary EN. This model showed high
sensitivity and specificity. CONCLUSION: Idiopathic EN is common. A basic
procedure including careful medical history-taking, a physical examination for
peripheral synovitis, 2 consecutive ASO determinations, a tuberculin skin test, and
chest radiography may be sufficient to diagnose EN.

==============================================
21.) [Erythema nodosum in sarcoidosis patients]
==============================================
Probl Tuberk. 1993;(6):25-7.

[Article in Russian]

Ozerova LV.

Erythema nodosum was registered in 45 from 502 sarcoidosis patients (9%).
Erythema often arose in initial sarcoidosis, but was also recorded in the disease
recurrences. Sarcoidosis of the skin and subcutaneous fat occurred in 16 and 4
patients, respectively, this incidence being half of that for erythema nodosum.
Sarcoidosis of the above sites is the second in occurrence among extrapulmonary
lesions following those of peripheral lymph nodes. Positive effects in the treatment
of erythema nodosum were reached after administration of corticosteroids,
noncorticosteroid anti-inflammatory drugs, physiotherapy, local therapy.

==============================================
22.) [Hairy cell leukemia associated with tuberculosis, disclosed by erythema
nodosum]
==============================================
Sem Hop. 1983 Oct 27;59(39):2716-7.

[Article in French]

Schved JF, Benoist D'Azu G, Brunel M, Vallat G.

A forty-two-year-old man presented with erythema nodosum of undeterminated
etiology and pancytopenia. A bone marrow biopsy revealed extensive hairy-cell
infiltration. Four months later, the diagnosis of pulmonary tuberculosis was
suggested by the appearance of a pulmonary infiltrate in the left upper lobe. Despite
antituberculous chemotherapy, the patient died. Post-mortem bacteriologic
confirmation was given by sputum culture.

==============================================
23.) [Erythema nodosum in Chlamydia pneumoniae infection]
==============================================
Tidsskr Nor Laegeforen. 1991 Apr 30;111(11):1369-70.

[Article in Norwegian]

Haugen O, Ritland S, Iveland H.

Medisinsk avdeling, Buskerud Sentralsykehus, Drammen.

Chlamydia pneumonia is now recognized as a species of the Chlamydia genus
distinct from C psittaci and C trachomatis species. It is a common cause of
pneumonia and other acute respiratory tract infections. We describe a patient with
erythema nodosum secondary to infection with C pneumoniae. Since this agent
usually causes a mild illness, with no distinct clinical findings, we recommend adding
serological tests for C pneumoniae to other relevant laboratory investigations in
patients with erythema nodosum.

==============================================
24.) [Sweet syndrome and erythema nodosum in ulcerative colitis, refractory to
steroids: successful treatment with tacrolimus]
==============================================
Med Klin (Munich). 2001 Feb 15;96(2):105-8.

[Article in German]

Fellermann K, Rudolph B, Witthoft T, Herrlinger KR, Tronnier M, Ludwig D,
Stange EF.

Medizinische Klinik I, Bereich Gastroenterologie, Universitatsklinikum Lubeck.
[email protected]

BACKGROUND: Inflammatory bowel disease is accompanied by cutaneous
manifestations in about 10% of cases. Erythema nodosum and pyoderma
gangraenosum are most frequently observed, which often subside on treatment of
the underlying disease. CASE REPORT: A 30-year-old male with a history of
long-standing ulcerative colitis experienced an acute attack despite treatment with
azathioprine. Further he noticed dull red, elevated and tender maculae on the
forelegs. A disseminated and papulosquamous exanthema arose on the back of the
trunk and the upper extremities without pruritus. Well-being was compromised and
blood sampling revealed an inflammatory response. High-dose steroids with
antibiotics were without benefit until they were combined with tacrolimus, an
immunosuppressive agent acting similar to ciclosporin. Remission occurred rapidly
and the skin lesions resolved. Six months later the patient is currently still in
remission and developed no signs of recurrent exanthema. CONCLUSION: The
cutaneous lesions are thought to be related to ulcerative colitis and were classified
as erythema nodosum and Sweet syndrome. This is the first report on the successful
use of tacrolimus in steroid-refractory ulcerative colitis with extraintestinal cutaneous
involvement.

==============================================
25.) Erythema nodosum associated with antiphospholipid antibodies: a report of
three cases.
==============================================
Lupus. 2000;9(8):641-5.

Nekhlyudov L, Gradzka M, Conti-Kelly AM, Greco TP.

Department of Internal Medicine, Yale University School of Medicine, New
Haven, CT, USA.

Erythema nodosum is a dermatologic condition characterized by painful,
erythematous nodules on the anterior surfaces of the lower extremities. Its
association with a variety of conditions has been previously described. We present
three cases of erythema nodosum in patients with elevated anticardiolipin
antibodies. In one patient, a temporal relationship was seen in the simultaneous
detection of antibodies and skin lesions. We propose an association between
erythema nodosum and the antiphospholipid antibody syndrome (APS).

==============================================
26.) Potassium iodide in the treatment of erythema nodosum and nodular vasculitis.
==============================================
Arch Dermatol. 1981 Jan;117(1):29-31.

Horio T, Imamura S, Danno K, Ofuji S.

Twenty-nine patients with erythema nodosum, nodular vasculitis, or erythema
nodosum-like lesions associated with Behcet's syndrome were treated with
potassium iodide. Administration of the drug for systemic effect showed a
substantial effect in 11 of 15 patients with erythema nodosum, seven of ten with
nodular vasculitis, and one of four with leg lesions of Behcet's syndrome. Relief of
subjective symptoms, including tenderness, joint pain, and fever, occurred within 24
hours. Substantial improvement in the eruption occurred within a few days, and the
lesions disappeared completely ten to 14 days after therapy was initiated. The
patients to whom the medication was administered shortly after the initial onset of
erythema nodosum seemed to respond most satisfactorily. The effect of the drug
was marked in the patients with positive C-reactive protein reactions, joint pains,
and/or fever. Possible mechanisms by which potassium iodide exerts its effect are
discussed.


==============================================
27.) Primary tuberculosis cases presenting with erythema nodosum.
==============================================
J Dermatol. 2004 Jan;31(1):66-8.

Mert A, Ozaras R, Tabak F, Ozturk R.

Infectious Diseases and Clinical Microbiology, Cerrahpasa Medical Faculty,
University of Istanbul, Turkey.

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%.


==============================================
28.) [Ulcerative colitis concomitant with pyoderma gangrenosum and erythema
nodosum--presentation of two cases]
==============================================
Przegl Lek. 2001;58(10):945-9.

[Article in Polish]

Wojas-Pelc A, Wielowieyska-Szybinska D, Setkowicz M, Szybinski P,
Bogdaszewska-Czabanowska J.

Katedra i Klinika Dermatologii Collegium Medicum Uniwersytet Jagiellonski,
Krakow.

Authors present case of a 28-year old woman with skin symptoms of pyoderma
gangrenosum and ulcerative colitis seriously advanced. The patient benefited from
wide resection of the colon and steroid therapy. The other patient was 23-year old
woman with ulcerative colitis concomitant with skin changes of erythema nodosum.
In this case steroid therapy gave also a very good effect. We tried to find
pathogenetic connection between these diseases based on the reports from the
medical literature.

==============================================
29.) Erythema nodosum heralding recurrent Hodgkin's disease.
==============================================
Cancer. 1985 Sep 15;56(6):1470-2.

Simon S, Azevedo SJ, Byrnes JJ.

The association of erythema nodosum with Hodgkin's disease is acknowledged,
although not well-documented in the literature. Two patients with long remissions of
their Hodgkin's disease manifested persistent erythema nodosum beginning 7 and 6
months, respectively, before relapse was clinically evident. The skin lesions in both
patients partially responded to treatment with indomethacin, but did not resolve
completely until chemotherapy was instituted. Erythema nodosum probably reflects
an important change in the balance of biologic forces between the host and the
neoplasm, the nature of which can only be speculated upon at this time. Erythema
nodosum should be considered a warning signal of impending relapse in a patient
with a history of Hodgkin's disease.


==============================================
30.) Erythema nodosum of dental origin.
==============================================
Clin Investig. 1992 Dec;70(12):1073-8.

Kirch W, Duhrsen U.

I Medizinische Klinik, Christian-Albrechts-Universitat Kiel.

The association of erythema nodosum and dental infectious foci has rarely been
described in the literature. This report concerns four women who developed
erythema nodosum either following dental treatment associated with gingival
bleeding or due to infectious dental foci. In these cases, tooth extraction, removal of
dental deposits, interrupted pulp treatment, apical periodontitis, or a relicted root
were identified as causes of the development of erythema nodosum. Upon
admission to the hospital, these patients also presented fever and and a maximally
elevated erythrocyte sedimentation rate (ESR). In all instances, surgical treatment of
the dental foci and/or administration of antibiotics rapidly led to the regression of the
erythema nodosum, as well as to the normalization of body temperature and ESR.
The cases described indicate that antecedent dental treatment and the possible
presence of infectious dental foci should be considered in the differential diagnosis
of erythema nodosum when taking the patient's medical history. This approach may
avoid unnecessary, possibly invasive diagnostic procedures and can lead to rapid
improvement in the patient's clinical status.

==============================================
31. Erythema nodosum and giardia intestinalis.
==============================================
Clin Rheumatol. 1985 Dec;4(4):481-3.

Giordano N, Fioravanti A, Mariani A, Marcolongo R.

We present the first report of erythema nodosum occurring in a woman with an
intestinal infection due to giardia lamblia, an association not previously described.
The authors suggest the possible role of giardia infection in the pathogenesis of
erythema nodosum.

==============================================
32.) Erythema nodosum following typhoid vaccination.
==============================================
Scott Med J. 1985 Jul;30(3):173.

Thomson BJ, Nuki G.

Erythema nodosum has recently been recognised in association with salmonella
infection (1). We report a case of classical erythema nodosum which developed
following a typhoid vaccination.

==============================================
33.) Salmonella gastroenteritis--another cause of erythema nodosum.
==============================================
Br J Dermatol. 1980 Mar;102(3):339-40.

Scott BB.

Although there are many causes and associations of erythema nodosum, it remains
a useful sign often giving a clue to the diagnosis of a puzzling illness. It is therefore
important for clinicians to be aware of all the possible causes and associations. The
following report is of a patient in whom typical erythema nodosum developed
during the course of severe salmonella gastroenteritis.

==============================================
34.) Onset of erythema nodosum during pregnancy: a case report.
==============================================
Clin Exp Obstet Gynecol. 1998;25(1-2):40-1.

Coaccioli S, Donati L, Di Cato L, Puxeddu A, Villani C.

Medical Clinic, University of Perugia S. Maria Hospital, Termi, Italy.

Publication Types:
Case Reports
==============================================

==============================================
35.) Erythema nodosum associated with acute cytomegalovirus mononucleosis in an
adult.
==============================================
Arch Intern Med. 1988 Feb;148(2):323-4.

Spear JB, Kessler HA, Dworin A, Semel J.

Department of Medicine, Rush-Presbyterian-St Luke's Medical Center, Chicago.

Acute cytomegalovirus mononucleosis has been associated with maculopapular
rashes, petechiae, purpura, urticaria, ulcerative lesions, and vesicular eruptions.
Although erythema nodosum has been reported in association with a number of
infectious and noninfectious diseases, to our knowledge it has not been associated
with cytomegalovirus infections. We report the first case of an adult patient with
acute cytomegalovirus mononucleosis who presented with erythema nodosum.

==============================================
36.) [Erythema nodosum in Campylobacter jejuni colitis]
==============================================
Schweiz Med Wochenschr. 1990 Jun 23;120(25):946-7.

[Article in German]

Frohli P, Hanselmann R, Koelz HR.

Gastroenterologie, Medizinische Klinik, Stadtspital Triemli, Zurich.

We report the case of a 27-years-old woman with erythema nodosum associated
with ulcerative colitis due to Campylobacter jejuni as diagnosed by serology,
endoscopy and histology. This case indicates a hitherto rarely described etiology of
erythema nodosum.

==============================================
37.) Granulomatous mastitis--a rare cause of erythema nodosum.
==============================================
Postgrad Med J. 1987 Jul;63(741):581-2.

Adams DH, Hubscher SG, Scott DG.

Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK.

Granulomatous mastitis is a recently described, rare condition of unknown
aetiology. It occurs in young, parous women as a tender extra-areolar breast lump
and therefore needs to be differentiated from carcinoma. Histologically, a discrete
granulomatous lobulitis is seen and because of morphological similarities to
granulomatous thyroiditis it has been suggested it may be immunologically mediated.
We present a patient in whom granulomatous mastitis presented with periarthritis
and erythema nodosum, an association not previously described.

==============================================
38.) Erythema nodosum in the Negev area--a survey of 50 patients.
==============================================
Isr J Med Sci. 1987 Dec;23(12):1228-31.

Erez A, Horowitz J, Sukenik S.

Department of Medicine A, Soroka Medical Center, Beer Sheva, Israel.

Fifty patients in the Negev area with erythema nodosum (EN) were studied
retrospectively. The clinical picture and demographic characteristics did not differ
markedly from those in the literature. In contrast to most European studies but like
those from Egypt, we found streptococcal pharyngitis to be the major cause of EN.
Conspicuously, sarcoidosis is a rare cause of EN in the Negev. The low incidence
of EN in the Negev--2 cases/100,000 people per year--as opposed to Europe--
14 cases/100,000 people per year--is hardly explained by the low occurrence of
sarcoidosis in Israel. Other factors, unknown at present, may account for this low
incidence.

==============================================
39.) Immunoglobulin E in erythema nodosum.
==============================================
Arch Dis Child. 1976 May;51(5):391-3.

Mandalenaki-Lambrou C, Thomaidis T, Benetos S, Ladis B, Matsaniotis N.

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.


==============================================
40.) [Erythema nodosum association with malignant lymphoma]
==============================================
Medicina (Kaunas). 2003;39(5):438-42.

[Article in Lithuanian]

Pileckyte M, Griniute R.

Clinic of Rheumatology, Kaunas University of Medicine, Lithuania.
[email protected]

Erythema nodosum is the most frequent clinicopathological variant of the
panniculitides. The disorder is a cutaneous reaction consisting of inflammatory
nodular lesions, usually located on the lower extremities. It may be associated with
a wide variety of diseases, infections, sarcoidosis, rheumatologic diseases,
inflammatory bowel diseases, medications and malignancies. Relationship between
erythema nodosum and malignant lymphoma is described in the article. A review of
the literature suggest that the diagnosis of Hodgkin's and non-Hodgkin's disease
should be considered in patients with unexplained erythema nodosum.


 

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DATA-MEDICOS/DERMAGIC-EXPRESS No 5-(122)  30/06/2.004 DR. JOSE LAPENTA R. 
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