A Case of Erythema Induratum

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A Case of Erythema Induratum
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Case Presentation

• 32 year old female, originally from India
• January painless left neck nodules
• April developed painful red nodules on lower
  legs.
• Accompanied by bilateral knee pain and ankle
  swelling.

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Erythema Induratum
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Case Presentation

• No respiratory symptoms, fever, chills, sweats.
• No genitourinary / abdominal / neurologic
  complaints.
• Deliberate 35 lbs. weight loss in two years.

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Case Presentation

• No preceding infection history / infected
  contacts / specific TB exposure.
• Traveled to India 2002
• HIV - when pregnant two years ago.
• Received BCG in past
• Lives with husband and 2.5 year old son

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Skin Biopsy
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Biopsy Results (June)

• Lobular panniculitis with areas of fat necrosis,
  histiocyte infiltrate, and granulomatous
  appearance throughout the fat lobules. Some
  vascular involvement with some vessels appearing
  completely necrotic. Scattering of lymphocytes
  and a few plasma cells. Compatible with lobular
  pnniculitis with vasculitis and therefore
  compatible with erythema induratum. AFB negative.

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Case Presentation

• Started on Celebrex, with improvement of skin,
  knee pain, ankle swelling.
• August 20 Assessed by ID.
• PPD positive with blistering, erythema and
  induration greater than 3 cm.
• Started on INH, referred for knee pain.

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PPD Reaction
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Case Presentation

• BP 120/70 H 155.5 cm W 102.5 kg
• 5-6 mobile, soft, non-tender nodes in left
  anterior chain and supraclavicular area. No
  other adenopathy.
• Normal respiratory, cardiac exam. Dull over
  Castells point.

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Case Presentation

• 2 cm red patch with central necrosis on right
  inner forearm
• Several bluish patches on lower legs, apparently
  healing. Some with darker centres.
• Tender over both anserine bursae, slight patellar
  crepitus.

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Case Presentations

• Normal CXR
• Hgb 127 MCV 70.9
• WBC 8.23 normal differential Plt 308
• ESR 26
• ALT 47 AST 58 ALP 116
• Hep B, C, VDRL negative
• U/A normal

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Extrapulmonary TB

• Can occur at initial infection or years later.
• Risk increased with immunocompromise, age,
  comorbidities.
• Increasingly seen due to HIV.
• Occurs in 20 of non-HIV patients with TB
• Occurs in 53-62 of TB patients with HIV

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Order of Frequency of Sites of Extrapulmonary TB

• Lymph nodes
• Pleura
• GU tract
• Skeleton (usually axial)
• Meninges
• Peritoneum
• All organ systems can be involved

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Tuberculous Lymphadenitis

• Usually unilateral painless swelling of cervical
  or supraclavicular nodes.
• Nodes usually discrete with normal overlying
  skin.
• If untreated, become matted, skin becomes
  inflamed and nodes rupture.
• May cause sinus tract formation, scarring.

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Tuberculous Lymphadenitis
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Tuberculous Lymphadenitis
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Tuberculous Lymphadenitis

• Systemic symptoms are unusual in isolated T.L. if
  HIV-negative.
• Formerly thought of as a childhood condition.
• Peak onset now 20-40 years
• FemalesgtMales
• More in Asian Pacific islanders

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Tuberculous Lymphadenitis

• Can also affect axillary, mesenteric,
  mediastinal, intramammary nodes.
• Mediastinal involvement can cause dysphagia,
  vocal cord paralysis, PA occlusion, bronchus
  constriction.
• Abdominal involvement causes jaundice, portal
  hypertension, portal vein thrombosis,
  renovascular HTN.

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Tuberculous Lymphadenitis

• Diagnosed by FNA and Ziehl-Neelsen staining.
  Yield improved by PCR.
• May require excisional biopsy for histology,
  culture, PCR.
• Treated in same manner as pulmonary TB.

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Erythema Induratum or Nodular Vasculitis

• TB isolated by PCR in 77 of cases.
• Usually middle-aged women.
• More common in obesity, venous insufficiency.
• Red, tender, subcutaneous nodules on posterior
  lower legs, ankles.
• May ulcerate and scar.

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Erythema Induratum or Nodular Vasculitis

• Lobular panniculitis with necrosis of adipocytes.
• Histiocytes infiltrate and ingest lipid, becoming
  foamy.
• Granulomatous appearance.
• Vasculitis of veins? Arteries? Both?
• In context of positive PPD or PCR, should be
  treated as TB.