|LETTER TO THE EDITOR
|Year : 2011 | Volume
| Issue : 2 | Page : 65-67
A case of tuberculous lymphadenitis with erythema nodosum
Sourya Acharya1, Samarth Shukla2, Amit Gupta1, Dinesh Singh1, SK Diwan1
1 Department of Medicine, JNMC, DMIMS University, Sawangi (Meghe), Wardhe, Maharashtra, India
2 Department of Pathology, JNMC, DMIMS University, Sawangi (Meghe), Wardhe, Maharashtra, India
|Date of Web Publication||17-Feb-2012|
Department of Medicine, JNMC, DMIMS University, Sawangi (Meghe), Wardha - 442 004, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Acharya S, Shukla S, Gupta A, Singh D, Diwan S K. A case of tuberculous lymphadenitis with erythema nodosum. Ann Nigerian Med 2011;5:65-7
|How to cite this URL:|
Acharya S, Shukla S, Gupta A, Singh D, Diwan S K. A case of tuberculous lymphadenitis with erythema nodosum. Ann Nigerian Med [serial online] 2011 [cited 2020 Jan 28];5:65-7. Available from: http://www.anmjournal.com/text.asp?2011/5/2/65/92956
Erythema nodosum (EN), a painful disorder of the subcutaneous fat, is the most common type of panniculitis. Generally, it is idiopathic, although the most common identifiable cause is streptococcal pharyngitis. EN may be the first sign of a systemic disease such as tuberculosis (TB), bacterial or deep fungal infection, sarcoidosis, inflammatory bowel disease, or cancer. Certain drugs, including oral contraceptives and some antibiotics, also may be etiologic. We present a case of tubercular lymphadenitis with EN.
A 23-year-old female presented to our clinic with painful lower extremity lesions of 3 weeks duration. She was well until 3 months before presentation when she reported symptoms of fatigue and weakness. She also noticed an enlarging mass on the left side of her neck. There was no history of fevers, chills, night sweats, or cough. Her symptoms did not respond to a course of oral doxycycline for 10 days. On general examination, her vital signs were normal. She had mild pallor. Palpation of the neck revealed matted lymph nodes which were firm in consistency and nontender. Skin over the nodes were normal. Both her forearms and legs revealed tender 0.5 to 1 cm erythematous tender nodules [Figure 1]. Systemic examination was normal. A fine needle aspirate of the enlarging lymph node revealed necrotizing granulomas on histology [Figure 2] and culture of the aspirate for acid fast bacilli grew Mycobacterium tuberculosis. Tuberculin skin test (TST) was positive by the Mantoux technique. A diagnosis of tuberculous lymphadenitis associated with EN was confirmed. The patient was started on quadruple therapy of isoniazid, rifampin, ethambutol, and pyrazinamide. Her lower limb skin lesions rapidly resolved over the subsequent month and her neck mass also diminished in size. She completed 6 months of antituberculous therapy with complete resolution of her lymphadenopathy.
|Figure 2: 1 H&E- stained section (4 x view) from wedge biopsy shows predominately thickened septae due to fibrosis. There is presence of periseptal granulation tissue along with inflammatory infiltrate mainly composed of lymphocytes, and radial granulomas with multinucleated giant cells arranged around a cleft like area. Inflammatory infiltrate extend to the periseptal areas of the fat lobules, findings consistently with late stage lesions of erythema nodosum|
Click here to view
EN is a panniculitis that affects subcutaneous fat in the skin. It usually first appears as outcropping of erythematous tender nodules.  Most nodules are located symmetrically on the ventral aspect of the lower extremities. There are no specific causes of EN, although certain immunologic triggers are responsible. Streptococcal infections are the most common identifiable etiology, especially in children. Drug and hormonal reactions, inflammatory bowel disease, TB and sarcoidosis are other common causes among adults. , Rarely it can be a sign of a serious disorder that potentially is treatable and management of the underlying etiology is the most definitive means of treatment.
EN occurs in approximately one to 5 per 100,000 persons. In adults, it is more common among women, with a male-to-female ratio of 1:6. , In children, the sex ratio is 1:1.  Peak incidence occurs in persons between 20 and 30 years of age, although it can occur at any age. EN is a nonspecific cutaneous immune-mediated reaction to a variety of antigens. Most direct and indirect evidence supports the involvement of a type IV delayed hypersensitivity response to numerous antigens. The characteristic lesions are collections of immune cells clustered in pockets within the subcutaneous layer of the skin. In some cases, the dermis (middle layer of the skin) may also be affected. EN often occurs in association with granulomatous diseases, including sarcoidosis, TB, and granulomatous colitis.  The nodules of EN vary from 1 to 10 cm in diameter. They are characteristically located in the subcutis and are poorly demarcated. Pretibial involvement is most common, although the extensor surfaces of the forearm, the thighs, and the trunk also may be affected. Initially nodules can be firm, but they usually become more fluctuant in due course of time. Individual nodules may last for 2 weeks; new outcroppings may continue to arise for up to 6 weeks. Healing occurs within 1-2 months. Lesions do not tend to ulcerate and usually resolve without atrophy or scarring. 
TB has long been linked with EN. , It has been reported to accompany primary tuberculous infection in 1-2% of British and 5-15% of Scandinavian cases. It is rare below the age of 7 years, with an increase in frequency up to puberty. It is common after puberty and 80-90% cases are females. Tuberculin conversion is said to precede the eruption by a few days to a few weeks in most cases, although EN may also occur later in primary or even post primary TB. The rash is probably a manifestation of the Arthus phenomenon, as in EN leprosum, where local deposits of immunoglobulins, complement and soluble mycobacterial antigens have been demonstrated. The Bacille Calmette-Gu
#233;rin vaccination and the TST have been associated with the development of EN. Furthermore, EN may be found in patients with highly positive reactions to the TST without detectable focus of tubercular infection. Our case is a rare example where EN is associated with extrapulmonary TB, suggesting a clear evidence of immunologic reaction and reactivation to tubercular antigens rather than a primary bacterial event. Mantoux test was also strongly positive in our case.
A study demonstrated that patients with EN were distinguished by enhanced mycobacterial growth restriction on functional assay, which was associated with marked activation and increased production of IFN gamma in response to stimulation with PPD of Mycobacterium tuberculosis. Children presenting with EN and a positive TST show evidence of responses associated with enhanced anti-mycobacterial immunity.  All patients with EN should be stratified by risk for tuberculosis exposure. Appropriate measures include TST, chest radiography, and sputum analysis for AFB. Antitubercular therapy should be initiated for EN in patients with positive TST reactions with or without a positively identified focus of infection. 
Although EN can be exquisitely tender, it tends to be self-limited. The most common approach is treatment of any underlying disorders and supportive therapy. Pain can be managed conservatively with nonsteroidal anti-inflammatory drugs. Systemic steroids in form of oral prednisolone (1 mg/kg body weight) have been advocated as a relatively safe therapeutic option if underlying infection, risk of bacterial dissemination or sepsis, and malignancy have been excluded by a thorough evaluation. Our case did not require steroids.
In conclusion, EN, a painful disorder of the subcutaneous fat is the most common type of panniculitis. It may be the first sign of a systemic disease such as TB. A lot of other conditions may have EN as a cutaneous manifestation in developed countries with low TB prevalence, but in developing countries TB should still be considered strongly and excluded. EN usually accompanies primary TB. This case highlights the association of EN with extrapulmonary TB.
| References|| |
|1.||Fox MD, Schwartz RA. Erythema nodosum. Am Fam Physician 1992;46:818-22. |
|2.||Kakourou T, Drosatou P, Psychou F, Aroni K, Nicolaidou P. Erythema nodosum in children: A prospective study. J Am Acad Dermatol 2001;44:17-21. |
|3.||Requena L, Yus ES. Panniculitis. Part I. Mostly septal panniculitis. J Am Acad Dermatol 2001;45:163-83. |
|4.||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. |
|5.||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. |
|6.||Mert A, Ozaras R, Tabak F, Ozturk R. Primary tuberculosis cases presenting with erythema nodosum. J Dermatol 2004;31:66-8. |
|7.||Brodie D, Schluger NW. The diagnosis of tuberculosis. Clin Chest Med 2005;26:247-71. |
|8.||Nicol MP, Kampmann B, Lawrence P, Wood K, Pienaar S, Pienaar D, et al. Enhanced anti mycobacterial immunity in children with erythema nodosum and a positive tuberculin skin test. J Invest Dermatol 2007;127:2152-7. |
|9.||Kumar B, Sandhu K. Erythema nodosum and antitubercular therapy. J Dermatolog Treat 2004;15:218-21. |
[Figure 1], [Figure 2]