Erythema Nodosum Workup

  • Author: Jeanette L Hebel, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Apr 17, 2012
 

Laboratory Studies

The following laboratory studies may be helpful:

  • Perform throat culture as part of the initial workup to exclude group A beta-hemolytic streptococcal infection.
  • Perform erythrocyte sedimentation rates often as part of the initial workup. The rate often is very high.
  • Antistreptolysin titer is elevated in some patients with streptococcal disease, but normal values do not exclude streptococcal infection. Evaluate titer levels during the initial workup, since streptococcal disease is a common cause of erythema nodosum.
  • Order stool examination, since along with the appropriate history of gastrointestinal complaints, a stool examination can exclude infection by Yersinia, Salmonella, and Campylobacter organisms.
  • Order blood cultures according to preliminary indications and findings.
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Imaging Studies

Order chest radiographs as part of the initial workup to exclude sarcoidosis and tuberculosis and to document hilar adenopathy.

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Other Tests

Intradermal skin tests can be used to exclude tuberculosis and coccidioidomycosis.

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Procedures

Because the diagnosis of erythema nodosum often is clinical, biopsy is reserved for diagnostically difficult cases. Punch biopsies usually are not adequate. Deep skin incisional biopsies are required to sample the subcutaneous tissue adequately. Findings are localized to the subcutaneous tissue.

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Histologic Findings

The classic features of erythema nodosum on histopathology include a septal panniculitis with slight superficial and deep perivascular inflammatory lymphocytic infiltrate.[13, 14] The septa of subcutaneous fat usually are thickened. As lesions evolve, periseptal fibrosis, giant cells, and granulation tissue appear. Miescher granulomas are a hallmark feature of erythema nodosum. Small well-defined nodular aggregates of histiocytes around a central stellate cleft are scattered throughout the lesions. A lymphohistiocytic infiltrate is noted in the septum and in small and medium-sized vessels.

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Contributor Information and Disclosures
Author

Jeanette L Hebel, MD  Department of Dermatology, Lancaster General Hospital

Jeanette L Hebel, MD is a member of the following medical societies: American Academy of Dermatology and American College of Mohs Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas Habif, MD  Adjunct Professor, Department of Internal Medicine, Section of Dermatology, Dartmouth Medical School

Thomas Habif, MD is a member of the following medical societies: American Academy of Dermatology and New Hampshire Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Timothy McCalmont, MD  Director, UCSF Dermatopathology Service, Professor of Clinical Pathology and Dermatology, Departments of Pathology and Dermatology, University of California at San Francisco; Editor-in-Chief, Journal of Cutaneous Pathology

Timothy McCalmont, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society of Dermatopathology, California Medical Association, College of American Pathologists, and United States and Canadian Academy of Pathology

Disclosure: Apsara Consulting fee Independent contractor

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Edward F Chan, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Joel M Gelfand, MD, MSCE  Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania

Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Nguyen GC, Torres EA, Regueiro M, et al. Inflammatory bowel disease characteristics among African Americans, Hispanics, and non-Hispanic Whites: characterization of a large North American cohort. Am J Gastroenterol. May 2006;101(5):1012-23. [Medline].

  2. 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(6-7):424-7. [Medline].

  3. Hassink RI, Pasquinelli-Egli CE, Jacomella V, Laux-End R, Bianchetti MG. Conditions currently associated with erythema nodosum in Swiss children. Eur J Pediatr. Nov 1997;156(11):851-3. [Medline].

  4. Mert A, Ozaras R, Tabak F, Ozturk R. Primary tuberculosis cases presenting with erythema nodosum. J Dermatol. Jan 2004;31(1):66-8. [Medline].

  5. Kakourou T, Drosatou P, Psychou F, Aroni K, Nicolaidou P. Erythema nodosum in children: a prospective study. J Am Acad Dermatol. Jan 2001;44(1):17-21. [Medline].

  6. Puavilai S, Sakuntabhai A, Sriprachaya-Anunt S, Rajatanavin N, Charuwichitratana S. Etiology of erythema nodosum. J Med Assoc Thai. Feb 1995;78(2):72-5. [Medline].

  7. Bottone EJ. Yersinia enterocolitica: the charisma continues. Clin Microbiol Rev. Apr 1997;10(2):257-76. [Medline].

  8. Labbe L, Perel Y, Maleville J, Taieb A. Erythema nodosum in children: a study of 27 patients. Pediatr Dermatol. Nov-Dec 1996;13(6):447-50. [Medline].

  9. Stolk-Engelaar VM, Hoogkamp-Korstanje JA. Clinical presentation and diagnosis of gastrointestinal infections by Yersinia enterocolitica in 261 Dutch patients. Scand J Infect Dis. 1996;28(6):571-5. [Medline].

  10. Farhi D, Cosnes J, Zizi N, et al. Significance of erythema nodosum and pyoderma gangrenosum in inflammatory bowel diseases: a cohort study of 2402 patients. Medicine (Baltimore). Sep 2008;87(5):281-93. [Medline].

  11. Sullivan R, Clowers-Webb H, Davis MD. Erythema nodosum: a presenting sign of acute myelogenous leukemia. Cutis. Aug 2005;76(2):114-6. [Medline].

  12. Grunewald J, Eklund A. Lofgren's syndrome: human leukocyte antigen strongly influences the disease course. Am J Respir Crit Care Med. Feb 15 2009;179(4):307-12. [Medline].

  13. Moraes AJ, Soares PM, Zapata AL, Lotito AP, Sallum AM, Silva CA. Panniculitis in childhood and adolescence. Pediatr Int. Feb 2006;48(1):48-53. [Medline].

  14. Requena L, Yus ES. Panniculitis. Part I. Mostly septal panniculitis. J Am Acad Dermatol. Aug 2001;45(2):163-83; quiz 184-6. [Medline].

  15. Marshall JK, Irvine EJ. Successful therapy of refractory erythema nodosum associated with Crohn's disease using potassium iodide. Can J Gastroenterol. Sep 1997;11(6):501-2. [Medline].

  16. Tseng S, Pak G, Washenik K, Pomeranz MK, Shupack JL. Rediscovering thalidomide: a review of its mechanism of action, side effects, and potential uses. J Am Acad Dermatol. Dec 1996;35(6):969-79. [Medline].

 
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Classic presentation of erythema nodosum with nodular red swellings over the shins.
 
 
 
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