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Erythema Induratum

Bazins Disease

Erythema induratum represents a chronic skin disease most often caused by Mycobacterium tuberculosis, consisting of chronic inflammatory nodules commonly located on the lower limbs of the patient. Similarities exist between this condition and nodular vasculitis, but at this time the two are considered separate entities.


Presentation

Erythema Induratum (EI) more often affects middle-aged women [1], but men and children can also acquire this illness.

An EI case usually suffers from pulmonary tuberculosis, but other sites of infection, like cervical lymphadenitis [2], renal parenchyma [3], epididymo-orchitis [4] or aortic valvular lesions of the same etiology [5] are possible. One study [6] even describes EI after Bacillus Calmette–Guérin (BCG) vaccine administration. In addition, it is important to evaluate the existence of human immunodeficiency virus (HIV) concomitant infection clinical traits [7].

The patients show erythematous or violaceous nodules, 1 - 4 cm in size, or plaques with a scaly surface located on the lower limbs, that may be tender and have a recurrent character, reappearing once every 3 or 4 months. Nodules sometimes cause shallow ulcers that heal, leaving scars and hyper pigmented areas. The affected regions, like calves, ankles, thighs, buttocks, but also trunk and arms are edematous. Disseminated forms have been described [8]. Pruritus is absent. The disease may worsen with cold weather. The clinical picture may be completed by the presence of distal painful peripheral neuropathy [9], cutis marmorata or erythrocyanosis. Systemic complaints are usually absent, but other dermal manifestations of tuberculosis, such as papulonecrotic tuberculids may coexist.

Cervical Lymphadenopathy
  • This is most often pulmonary tuberculosis with cervical lymphadenopathy second. Erythema induratum often remains undiagnosed or misdiagnosed because it can masquerade as other types of chronic nodules of the lower extremities.[patient.co.uk]
Sputum
  • Sputum and gastric washings were negative for acid-fast bacilli. Histology on a skin biopsy showed a granulomatous panniculitis with no histological evidence of Mycobacterium tuberculosis, consistent with erythema induratum.[ncbi.nlm.nih.gov]
  • In case an underlying active disease is suspected, the physician should order urine, early morning sputum, and gastric aspirates microbiological examination.[symptoma.com]
  • Other Early morning sputum, urine and gastric aspirates may be helpful to rule out an underlying active infection, but are generally negative. In cases with negative TB findings, a work up for hepatitis C and possibly HIV may be recommended.[dermatologyadvisor.com]
Productive Cough
  • She had recurring fevers particularly at night, lethargy, weight loss and a persistent non-productive cough. The Mantoux test was positive.[ncbi.nlm.nih.gov]
Liver Fibrosis
  • Evaluation of persistent serum transaminase elevations led to a diagnosis of chronic hepatitis C with bridging liver fibrosis.[ncbi.nlm.nih.gov]
Microscopic Hematuria
  • It has been done an urynalysis, which demonstrated acid pH urine, sterile pyuria and microscopic hematuria. It was then raised the diagnostic hypothesis of renal tuberculosis.[ncbi.nlm.nih.gov]
Pruritus Vulvae
  • vulvae 631 201 Pseudofolliculitis barbae 634 202 Pseudoxanthoma elasticum 638 203 Psoriasis 640 204 Psychogenic excoriation 651 205 Pyoderma gangrenosum 654 206 Pyogenic granuloma 659 207 Radiation dermatitis 662 208 Raynaud disease and phenomenon 665[books.google.com]

Workup

Workup should include a complete cell blood count with differential, inflammatory markers (such as the erythrocyte sedimentation rate) and liver function tests. M. tuberculosis infection can be diagnosed in may ways: interferon-gamma release assays [10] such as QuantiFERON--tuberculosis (TB) Gold In-Tube test and the T-SPOT-TB test [11]. The manifestation of pathognomonic lesions and a positive QuantiFERON exam establish the diagnosis, even if acid-fast bacilli are not detected or the thoracic radiography is normal [12]. The purified protein derivative tuberculosis skin test is positive in these patients and an exaggerated host immunologic response and hypersensitivity reaction are to be expected after administration. In case an underlying active disease is suspected, the physician should order urine, early morning sputum, and gastric aspirates microbiological examination.

Imaging modalities include thoracic radiographs (posteroanterior and lateral) that may show aspects of active or inactive tuberculosis. If the diagnosis cannot be established otherwise, an excisional biopsy should be done. The tissue will then be analyzed using hematoxylin-eosin, specific stains for acid-fast bacilli, but also for bacteria and fungi. In cases with negative tuberculosis findings, hepatitis C and HIV infection should be searched for. Furthermore, a histological analysis will depict a granulomatous panniculitis with possible inflammatory vasculitis [13], noncaseating granulomas and caseation-like necrosis. Other cell types, like giant, epithelioid cells or histiocytes are also encountered in late stages, while fresh lesions mainly contain lymphocytes. The presence of M. tuberculosis deoxyribonucleic acid in the excised tissue can be proven using polymerase chain reaction [14]. However, its absence does not confirm the non-existence of the ailment.

Staphylococcus Aureus
  • 423 139 Lymphocytoma cutis 425 140 Lymphogranuloma venereum 428 141 Lymphomatoid papulosis 430 142 Malignant atrophic papulosis 435 143 Malignant melanoma 438 144 Mastocytoses 443 145 Melasma 447 146 Merkel cell carcinoma 450 147 Methicillinresistant Staphylococcus[books.google.com]
Multiple Ulcerations
  • They break down to form small and multiple ulcers. Fresh crops of nodules appear in periphery of ulcer and ultimately break down. In nodular stage, pain is present; while it subsides in ulcerative stage.[en.wikipedia.org]
  • They break down to form small and multiple ulcers. Fresh crops of nodules appear in periphery of ulcer and ultimately break down.[ipfs.io]
Liver Biopsy
  • Subcutaneous nodule histology was compatible with erythema induratum of Bazin, and liver biopsy evidenced granulomatous hepatitis.[ncbi.nlm.nih.gov]

Treatment

  • Interestingly, lesions improve with antiviral treatment and, as shown in this case, the effect may be sustained after stopping treatment despite virologic relapse.[ncbi.nlm.nih.gov]
  • One patient had concurrent active pulmonary tuberculosis, and the other had a history of previous treatment for pulmonary tuberculosis. The treatment regimen for these patients is outlined.[ncbi.nlm.nih.gov]
  • Topical anti-TB treatment (3.75% isoniazid twice a day) was necessitated by the development of severe gastrointestinal upset and significant reduction in platelets after oral treatment with isoniazid and rifampicin.[ncbi.nlm.nih.gov]
  • We analysed clinicopathological features, responses to IGRA and the treatment courses. In addition, we compared positive rate of IGRA in patients with other diseases during the same period.[ncbi.nlm.nih.gov]
  • The treatment was instituted with rifampin, isoniazid and pyrazinamide, with complete regression.[ncbi.nlm.nih.gov]

Prognosis

  • Prognosis The prognosis is good if treated properly. To date, no fatal cases of erythema induratum have been reported. However, the chronic, recurrent, painful nodules and resultant scarring can be a source of significant morbidity.[emedicine.com]
  • Prognosis If TB is the cause, the lesions will disappear with appropriate TB treatment. Spontaneous resolution of lesions is common within a few months, leaving areas of postinflammatory hyperpigmentation and atrophic scarring.[patient.co.uk]

Etiology

  • An 81-year-old woman with a history of renal cell carcinoma and years of slowly, progressively enlarging pulmonary nodules of uncertain etiology presented with several weeks of painful lower extremity nodules.[ncbi.nlm.nih.gov]
  • It should be borne in mind that tuberculosis is an important etiological factor for Addison's disease.[ncbi.nlm.nih.gov]
  • In many countries, tuberculosis is still the main etiologic factor. We report a case of a 40-year-old woman who presented a course of protracted and recurrent episodes over five years of cutaneous lesions on her legs.[ncbi.nlm.nih.gov]
  • The etiology of erythema induratum, a rare disease of the skin in the United States but occasionally seen in natives of Asian countries, remains a source of debate.[ncbi.nlm.nih.gov]
  • Fastest Basicmedical Insight Engine Key Facts Terminology Granulomatous lobular panniculitis with vasculitis Etiology/Pathogenesis Mycobacterium species, Brucella species, hepatitis C Clinical Issues Usually multiple painful nodules on calves or shins[basicmedicalkey.com]

Epidemiology

  • […] vessels TERMINOLOGY Synonyms Erythema induratum of Bazin, nodular vasculitis Definitions Granulomatous lobular panniculitis with vasculitis ETIOLOGY/PATHOGENESIS Infectious Agents Mycobacterium species, Brucella species, hepatitis C CLINICAL ISSUES Epidemiology[basicmedicalkey.com]
  • ., hepatitis C, and hepatitis B. [ 1 ] Epidemiology The disease is still seen in countries where TB is rife but it is rarely seen in western societies. When it is, the type is more often Whitfield than Bazin.[patient.co.uk]
  • Epidemiologically, erythema induratum is an extremely rare diagnosis. The disease has a female predominance of up to 90% ( Bolognia, Jorizzo, & Schaffer, 2012 ). There is no racial predilection.[nursingcenter.com]
  • Epidemiology Incidence Although NV is quite common, erythema induratum is rare other than in India, Hong Kong, and some areas of South Africa.[unboundmedicine.com]
Sex distribution
Age distribution

Pathophysiology

  • We review the characteristics of EIB and examine how the unique presentation of peripheral neuropathy may relate to the pathophysiology of this disease.[ncbi.nlm.nih.gov]
  • Pathophysiology Predisposing factors include abnormal amount of subcutaneous fat, thick ankles and abnormally poor arterial supply. Abnormal arterial supply causes low-grade ischemia of ankle region.[ipfs.io]
  • Pathophysiology The disease or diseases represent an inflammatory reaction. One antigen is Mycobacterium tuberculosis.[patient.co.uk]
  • Most common (86%) form of cutaneous TB (tuberculid) in Hong Kong found between 1993 and 2002 Predominant age: 13 to 66 years (mean 37 years) Predominant sex: female (80–90%) male Etiology and Pathophysiology The morphologic, molecular, and clinical data[unboundmedicine.com]

Prevention

  • , Centers for Disease Control and Prevention.[5minuteconsult.com]
  • Safe sex precautions, including condom use Counsel regarding not sharing needles in order to prevent HIV or hepatitis C transmission.[unboundmedicine.com]
  • Rapidly find the answers you need with separate sections on diseases and disorders, differential diagnosis, clinical algorithms, laboratory results, and clinical preventive services, plus an at-a-glance format that uses cross-references, outlines, bullets[books.google.com]
  • If a blood vessel is inflamed, it can narrow or close off, this can limit, or even prevent, blood flow through the vessel and potentially damage organs. The most common type of panniculitis is erythema nodosum, which affects the shins.[knowyourdoctor.com.cy]
  • Can Be Treated (Centers for Disease Control and Prevention) Tuberculosis Facts - Testing for TB (Centers for Disease Control and Prevention) Tuberculosis Facts - You Can Prevent TB (Centers for Disease Control and Prevention) Tuberculosis: General Information[icdlist.com]

References

Article

  1. Cho K, Lee D, Kim C. Erythema induratum of Bazin. Int. J. Dermatol. 1996;35:802–8.
  2. Takahashi S, Negishi I, Tamura A, et al. The close association of lymphadenitis tuberculosa and erythema induratum of Bazin in Japanese patients. Dermatology. 2003;207:426–7.
  3. Daher E, Silva G, Pinheiro H, et al. Erythema induratum of Bazin and renal tuberculosis: report of an association. Rev Inst Med Trop Sao Paulo. 2004;46(5):295-8.
  4. Ramdial P, Calonje E, Sydney C, et al. Tuberculids as sentinel lesions of tuberculous epididymo-orchitis. J Cutan Pathol. 2007;34(11):830-6.
  5. Sughimoto K, Nakano K, Gomi A, et al. Aortic valve stenosis associated with Bazin's disease. J Heart Valve Dis. 2007;16(2):212-3.
  6. Inoue T, Fukumoto T, Ansai S, et al. Erythema induratum of Bazin in an infant after Bacille Calmette-Guerin vaccination. J Dermatol. 2006;33(4):268-72.
  7. Varshney A, Goyal T. Incidence of various clinico-morphological variants of cutaneous tuberculosis and HIV concurrence: a study from the Indian subcontinent. Ann Saudi Med. 2011;31(2):134-9.
  8. Teramura K, Fujimoto N, Nakanishi G, et al. Disseminated erythema induratum of Bazin. Eur J Dermatol. 2014;24(6):697–8.
  9. Zakeri K, Oganesyan G, Lee RA, et al. Erythema induratum of Bazin presenting as peripheral neuropathy. Cutis. 2015;96(3):E1-4.
  10. Prajapati V, Steed M, Grewal P, et al. Erythema induratum: case series illustrating the utility of the interferon-? release assay in determining the association with tuberculosis. J Cutan Med Surg. 2013;17(S1):S6-S11.
  11. Angus J, Roberts C, Kulkarni K, et al. Usefulness of the QuantiFERON test in the confirmation of latent tuberculosis in association with erythema induratum. Br J Dermatol. 2007;157(6):1293-4.
  12. Sim JH, Whang KU. Application of the QuantiFERON®-TB Gold test in Erythema Induratum. J Dermatolog Treat. 2014;25(3):260-3.
  13. Segura S, Pujol RM, Trindade F, et al. Vasculitis in erythema induratum of Bazin: a histopathologic study of 101 biopsy specimens from 86 patients. J Am Acad Dermatol. 2008;59(5):839-51.
  14. Mascaro J, Baselga E. Erythema induratum of Bazin. Dermatol. Clin. 2008;26:439-45.

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Last updated: 2019-07-11 21:25