A 26-year-old Caucasian woman presents for evaluation of painful, red nodules on her bilateral shins that started several days ago. The nodules were initially bright red. They are now turning darker and becoming flatter. She had a similar occurrence several months ago where she developed a bruise-like discoloration for several weeks that resolved without scarring. Her review of systems is positive for a low-grade fever, malaise, and some joint pains. Additionally, she admits to intermittent bouts of abdominal pain, as well as a few episodes of bloody diarrhea.
This patient was ultimately diagnosed with erythema nodosum that was found to be associated with inflammatory bowel disease. Figures 59-1 and 59-2 demonstrate characteristic erythema nodosum on the classic locations. She was prescribed rest and nonsteroidal anti-inflammatory drugs, and was referred to a gastroenterologist. After initiating treatment for Crohn disease, the nodules healed without scarring and did not recur.
Erythema nodosum in a patient with underlying Kikuchi disease. (Photograph courtesy of Matthew Zirwas, MD.)
Erythema nodosum in a patient with no underlying abnormality. (Photograph courtesy of Matthew Zirwas, MD.)
The most common panniculitis that is typically seen in young women between the ages of 20 and 40. Erythema nodosum is seen 3 to 6 times more frequently in women than men. An underlying cause can be found in approximately two-thirds of cases.1
In children, it is most commonly associated with streptococcal pharyngitis or perianal infection.
In adults, it is most commonly associated with drug ingestion, sarcoidosis, or upper respiratory tract infection. Table 59-1 presents the most common associations seen in teenagers and adults.
TABLE 59-1.Common Associations of Erythema Nodosum and Clinical Pearls |Favorite Table|Download (.pdf) TABLE 59-1. Common Associations of Erythema Nodosum and Clinical Pearls
|Common Associations of Erythema Nodosum ||Frequency Seen in 106 Conse cutive Patients Older Than 14 Years of Age Diagnosed in Spain1 ||Clinical Pearl |
|Idiopathic ||34.3% ||Treatments: |
First line: nonsteroidal anti-inflammatory drugs + rest
Second line: corticosteroids
|Sarcoidosis ||22% ||Lofgren syndrome: |
Erythema nodosum, hilar lymphadenopathy, and arthritis
Most patients with this presentation will undergo remission
|Upper respiratory infection ||12.7% ||Check throat culture and antistreptolysin-O titer. |
|Upper respiratory infection + drug ||6.9% ||If possible, stop recent drugs |
|B-hemolytic streptococcal infection ||6.9% ||Most common cause in children |
|Tuberculosis ||4.9% ||Chest x-ray, PPD, especially in high-risk individuals |
|Inflammatory bowel disease ||3% ||Crohn disease slightly more common than ulcerative colitis |
|Drugs alone ||2.9% ||Numerous drugs have been associated with this condition9 |
|Other ||6.4% ||Geographic variants exist. Coccidioidomycosis and histoplasmosis can frequently be associated with erythema nodosum in acute infections |