|Year : 1992 | Volume
| Issue : 2 | Page : 80-83
Erythema nodosum an analysis of 100 cases
ML Khatri, M Shafi
M L Khatri
Source of Support: None, Conflict of Interest: None
An analysis of 100 cases of erythema nodosum (EN) is presented. Likely causative factors were : focal streptococcal infection in 56, oral contraceptives in 4, tuberculosis in 3, kerion (due to Trichophyton mentagrophytes) in 2, pregnancy in 2, Behcet's disease in 2 and amoebiasis in 1 patient. A definite cause could not be elicited in 30 patients. Clinical features were almost similar to previously reported studies, except unilateral distribution in 3 patients. An unusual association of subcutaneous emphysema of the chest with recurrent episode of EN was observed in 1 female patient. Forty-one patients with moderate and severe presentation, treated with indomethacin, showed quicker resolution of the lesions.
Keywords: Erythema nodosum, Indomethacin
|How to cite this article:|
Khatri M L, Shafi M. Erythema nodosum an analysis of 100 cases. Indian J Dermatol Venereol Leprol 1992;58:80-3
| Introduction|| |
Erythema nodosum (EN) as a distinct clinical entity was recorded by Willan in 1798  and subsequently by Erasmus Wilson in 1842.  The condition is characterized by appearance of acute erythematous tender nodules over the anterior aspect of legs, regressing spontaneously with bruise like colour changes and healing without scarring in 3 to 6 weeks. Lesions can affect other sites of the body like forearms and thighs. Constitutional symptoms are usually seen. 
High incidence of EN in our indoor patients prompted us to undertake a systematic study of these cases.
| Materials and Methods|| |
This study was conducted on 100 patients seen over a period of about 2 years, since February 1987. All the patients were admitted in the hospital for assessment and treatment. Details of the history, physical findings, laboratory data and follow-up were recorded. The diagnosis of EN was based on typical clinical features and histopathologic data, when needed.
| Results|| |
All the patients were Libyan nationals. The age and sex incidence is given in [Table - 1]. Past history of EN was found in 19 patients and number of episodes ranged from 1 to 15. Significant past history is summarized in [Table - 2]. Eleven patients were on oral contraceptive pill and 10 were pregnant (9 in 1st trimester and 1 in 2nd trimester). Family history of EN could not be elicited in any of the patients.
All the patients had erythematous tender nodules of variable size with raised temperature on the sites shown in [Table - 3]. All except 3 patients had bilateral lesions. Fourteen patients had joint involvement with pain and swelling and the ankle joints were affected in most of them. Erythema multiforme plaque type was associated in 4 patients, cervical lymphadenitis in 1 and subcutaneous emphysema on the chest in 1. Two children had kerion. One patient was a known case of Behcet's disease for last 5 years, while another young man with EN developed other features of Behcet's disease during hospitalisation.
Results of relevant investigations are summarized in [Table - 4].
After analysing the history, clinical features and laboratory data, we reached to the following conclusion regarding the likely causative factors in our cases.
1. Focal streptococcal infection 56 patients
2. Oral contraceptives 4 "
3. Tuberculosis 3
(due to T. mentagrophytes) 2
5. Pregnancy 2 "
6. Behcet's disease 2 "
7. Amoebiasis 1 "
8. Unknown causes 30 "
Mild cases were given paracetamol. Forty-seven cases with moderate to severe presentation were given indomethacin suppository (100mg) at bed time. Five patients did not show any improvement and 1 had adverse effect after indomethacin, so it was discontinued and 2 to 3 weeks' course of prednisolone was given to him in tapering doses after excluding tuberculosis. All the 47 patients (41 treated with indomethacin and 6 treated with prednisolone) showed quick resolution of lesions within 2 to 4 weeks. The patients with evidence of streptococcal infection were given injectable benzyl penicillin in severe and moderate cases and oral penicillin in mild cases. The resolution of the lesions was quicker in the patients on injectable penicillin. Two patients with kerion were given griseofulvin for 6 weeks and 1 patient with amoebiasis was given metronidazole for 10 days.
Nine patients came with recurrence of EN with number of episodes ranging between 1 to 3 within the 2 years of study period.
| Comments|| |
The incidence of EN in the present study is significantly high (7 percent of indoor patients). Male : female ratio was 1:6. Similar ratio is reported in most of the previously reported series.  In childhood cases there was a male preponderance, with male: female ratio of 7 : 3. Gordon  reported equal ratio in such cases. The peak incidence was between 21 to 30 years of age. Johnson  and Vesy et al  reported peak incidence between 20 to 50 years.
The clinical features in our cases were almost similar to the previous studies.  One female patient had repeated subcutaneous emphysema of chest, associated with recurrent episodes of EN. Such an association has not been reported in the past.
Similar to previous studies,  focal streptococcal infection was the most common cause detected in the present study. ASOT was significantly high in 54 patients,. while throat swab culture revealed B-hemolytic streptococci in 17 patients. All of these patients had significant leucocytosis and good response to penicillin therapy. A significant association of EN with oral contraceptives was found in 4 patients. We could not detect any other causative factor in these cases. In 1 patient we could confirm it by readministration of pill, which produced the lesions again. The other 3 patients did not agree for this trial but they stopped the pill completely and did not come with recurrence of EN for 1 year. It shows definite relationship of EN to oral contraceptives, either as the main causative factor or as a supportive factor with some other unknown underlying cause.
Similar observations were recorded in the previous reports ,, Among the 10 pregnant patients, no other cause of EN could be detected in 2, one of them had similar episodes of EN in 1st trimester of previous 3 pregnancies, while the other also had 1 episode in the 1st trimester of previous pregnancy. Such an association has been reported in the past, , whereas Daw  reported EN occurring towards the end of 2 successive pregnancies.
Smaller dermal nodules occurring as skin manifestation of Behcet's disease is well recorded in the past.  We have observed typical lesions of EN in 2 of our patients with Behcet's disease, included in this study. In the past we have noticed similar lesions in our patients of Behcet's disease. 
One of our patients had chronic amoebiasis. She was treated with metronidazole. The EN lesions resolved within 2 weeks. We could not elicit any other cause in this patient, hence the possible cause in this case may be amoebiasis. A case of EN associated with invasive amoebiasis has been reported in the past. 
Forty-one patients out of 47, treated with indomethacin, showed quicker resolution of lesions within 2-4 weeks. Similar results were reported by Ubogy, and Perselin. 
| References|| |
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|2.||Darlington LG. Erythema nodosum and oral contraceptives. Br J Dermatol 1974; 90: 209-12. [PUBMED] |
|3.||Merk H, Ruzika T. Oral contraceptives as a cause of erythema nodosum. Arch Dermatol 1981; 117: 454. |
|4.||Salvatore MA, Lynch PJ. Five cases of erythema nodosum related to pregnancy and oral contraceptive use. Arch Dermatol 1980; 116: 557-8. [PUBMED] |
|5.||Khatri ML, Shafi M. Behcet's disease (A study of 23 cases from Tripoli, Libya). Ind J Dermatol Venereol Leprol 1987; 53 : 282 - 5. |
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|7.||Ubogy Z, Persellin RH. Suppression of Erythema nodosum by Indomethacin. Acta Dermatovenereol (Stockholm) 1982; 62: 265-7. |
[Table - 1], [Table - 2], [Table - 3], [Table - 4]
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