eMedicine Specialties > Dermatology > Diseases of the Vessels

Erythema Induratum (Nodular Vasculitis): Differential Diagnoses & Workup

Author: Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Private Practice
Coauthor(s): Kwang-Hyun Cho, MD, Professor, Department of Dermatology, Seoul National University College of Medicine, Korea; Beom Joon Kim, Clinical Fellow, Clinical Fellow of Dermatology, Department of Dermatology, Seoul National University Hospital
Contributor Information and Disclosures

Updated: Mar 17, 2008

Differential Diagnoses

Cold Panniculitis

Other Problems to Be Considered

Chilblain
Subcutaneous panniculitic T-cell lymphoma
Erythema nodosum leprosum
Factitial panniculitis
Infectious panniculitis due to agents other than M tuberculosis
Alpha-1 antitrypsin deficiency panniculitis
Pancreatic panniculitis
Lupus panniculitis

Workup

Laboratory Studies

  • A complete blood cell count may be performed.
  • The erythrocyte sedimentation rate may be increased.
  • The diagnosis of erythema can be made with the help of polymerase chain reaction testing.11,12,13
  • The QuantiFERON test is a simple blood test that can confirm the presence of latent tuberculosis in association with erythema induratum.14

Imaging Studies

  • Chest radiography may be performed. Search for evidence of active or previous infection.

Other Tests

  • Polymerase chain reaction provides rapid and sensitive detection of M tuberculosis in formalin-fixed, paraffin-embedded specimens. Polymerase chain reaction can be applied to differentiating nodular vasculitis from erythema induratum of Bazin because the demonstration of mycobacteria emerges as the only reliable criterion in erythema induratum of Bazin type.

Procedures

  • Some patients are highly sensitive to tuberculin PPD. Patients should be tested with a 1:10,000 dilution Mantoux test (see Media File 4).
  • An excisional biopsy containing adequate subcutaneous fat is recommended. Special stains for bacterial, fungal, and acid-fast organisms, as well as tissue for culture of these organisms, are generally obtained.

Histologic Findings

Findings consist of a mixed septal and lobular granulomatous panniculitis with neutrophilic vasculitis (see Media Files 2-3). Caseationlike necrosis may also be seen. The histologic features are not specific; they vary depending on the age of the lesion undergoing biopsy and the overlap with other forms of panniculitis. Vasculitis is not always identified and is not a requisite for the diagnosis. The presence of both septal granulomatous inflammation and lobular granulomatous inflammation is, nonetheless, characteristic of erythema induratum and contrasts with erythema nodosum (primarily septal) and polyarteritis nodosa (medium vessel vasculitis with minimal lobular inflammation).

More on Erythema Induratum (Nodular Vasculitis)

Overview: Erythema Induratum (Nodular Vasculitis)
Differential Diagnoses & Workup: Erythema Induratum (Nodular Vasculitis)
Treatment & Medication: Erythema Induratum (Nodular Vasculitis)
Follow-up: Erythema Induratum (Nodular Vasculitis)
Multimedia: Erythema Induratum (Nodular Vasculitis)
References
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References

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  2. Ho CK, Ho MH, Chong LY. Cutaneous tuberculosis in Hong Kong: an update. Hong Kong Med J. Aug 2006;12(4):272-7. [Medline].

  3. Inoue T, Fukumoto T, Ansai S, Kimura T. Erythema induratum of Bazin in an infant after Bacille Calmette-Guerin vaccination. J Dermatol. Apr 2006;33(4):268-72. [Medline].

  4. Leahy TR, Downey P, Ramsay B, Philip RK. Erythema induratum of Bazin and episcleritis in a 6 year old girl. Arch Dis Child. Nov 2005;90(11):1132. [Medline].

  5. Friedman PC, Husain S, Grossman ME. Nodular tuberculid in a patient with HIV. J Am Acad Dermatol. Aug 2005;53(2 Suppl 1):S154-6. [Medline].

  6. Daher Ede F, Silva Junior GB, Pinheiro HC, Oliveira TR, Vilar Mdo L, Alcantara KJ. Erythema induratum of Bazin and renal tuberculosis: report of an association. Rev Inst Med Trop Sao Paulo. Sept-Oct 2004;46(5):295-8. [Medline].

  7. Silva MT, Antunes SL, Rolla VC, Galhardo MC, Sant'ana FM, do Valle AF. Distal painful peripheral neuropathy associated with erythema induratum of Bazin. Eur J Neurol. Dec 2006;13(12):e5-6. [Medline].

  8. Ramdial PK, Calonje E, Sydney C, Subrayen S, Meyiwa PS, Aboobaker J. Tuberculids as sentinel lesions of tuberculous epididymo-orchitis. J Cutan Pathol. Nov 2007;34(11):830-6. [Medline].

  9. Sughimoto K, Nakano K, Gomi A, Nakatani H, Nakamura Y, Sato A, et al. Aortic valve stenosis associated with Bazin's disease. J Heart Valve Dis. Mar 2007;16(2):212-3. [Medline].

  10. Degonda Halter M, Nebiker P, Hug B, Oberholzer M, Fluckiger U, Bassetti S. [Atypical erythema induratum Bazin with tuberculous osteomyelitis]. Internist (Berl). Aug 2006;47(8):853-6. [Medline].

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  14. Angus J, Roberts C, Kulkarni K, Leach I, Murphy R. Usefulness of the QuantiFERON test in the confirmation of latent tuberculosis in association with erythema induratum. Br J Dermatol. Dec 2007;157(6):1293-4. [Medline].

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  22. Koga T, Kubota Y, Kiryu H, Nakayama J, Matsuzoe D, Shirakusa T. Erythema induratum in a patient with active tuberculosis of the axillary lymph node: IFN-gamma release of specific T cells. Eur J Dermatol. Jan-Feb 2001;11(1):48-9. [Medline].

  23. Requena L. Normal subcutaneous fat, necrosis of adipocytes and classification of the panniculitides. Semin Cutan Med Surg. Jun 2007;26(2):66-70. [Medline].

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Further Reading

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Keywords

tuberculosis-associated erythema induratum, TB-associated erythema induratum, erythema induratum of Bazin

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Contributor Information and Disclosures

Author

Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Private Practice
Noah S Scheinfeld, MD, JD, FAAD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Optigenex Consulting fee Independent contractor

Coauthor(s)

Kwang-Hyun Cho, MD, Professor, Department of Dermatology, Seoul National University College of Medicine, Korea
Disclosure: Nothing to disclose.

Beom Joon Kim, Clinical Fellow, Clinical Fellow of Dermatology, Department of Dermatology, Seoul National University Hospital
Disclosure: Nothing to disclose.

Medical Editor

Jean-Hilaire Saurat, MD, Chair, Professor, Department of Dermatology, University of Geneva, Switzerland
Jean-Hilaire Saurat, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory
Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

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 None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology
Disclosure: elsevier Royalty Other; american college of physicians Honoraria Other

 
 
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