eMedicine Specialties > Dermatology > Diseases of the Vessels

Erythema Induratum (Nodular Vasculitis)

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
Contributor Information and Disclosures

Updated: Jan 7, 2010

Introduction

Background

In 1861, Bazin gave the name erythema induratum to a nodular eruption that occurred on the lower legs of young women with tuberculosis. In 1945, Montgomery et al, while fully acknowledging the existence of tuberculosis-associated erythema induratum, coined the term nodular vasculitis to describe chronic inflammatory nodules of the legs that showed histopathologic changes similar to those of erythema induratum, that is, vasculitis of the larger vessels and panniculitis.

Erythema induratum and nodular vasculitis had been considered the same disease entity for a long time. However, nodular vasculitis is now considered a multifactorial syndrome of lobular panniculitis in which tuberculosis may or may not be one of a multitude of etiologic components. Therefore, erythema induratum/nodular vasculitis complex is classified into 2 variants: erythema induratum of Bazin type and nodular vasculitis or erythema induratum of Whitfield type. The Bazin type is related with tuberculous origin, but Whitfield type is not.

One report describes erythema induratum of 3 years’ duration caused by chronic hepatitis C infection in a 49-year-old man. The erythema induratum responded to pegylated interferon and ribavirin therapy for 48 weeks.¹

Motswaledi and Schulz² noted that erythema induratum of Bazin, lichen scrofulosorum, and papulonecrotic tuberculide are the 3 recognized tuberculides, which are sequelae of immunologic reactions to hematogenously dispersed antigenic components of Mycobacterium tuberculosis. A fourth tuberculide, called nodular granulomatous phlebitis, is distinct from erythema induratum.

Related eMedicine articles include Tuberculosis (emergency medicine focus), Tuberculosis (infectious disease focus), Tuberculosis (ophthalmology focus), and Tuberculosis (pediatric focus).

Pathophysiology

The morphologic, molecular, and clinical data suggest that erythema induratum and nodular vasculitis represent a common inflammatory pathway, that is, a hypersensitivity reaction to endogenous or exogenous antigens. One such antigen is the tubercle bacillus. Patients with erythema induratum have a positive tuberculin skin test result and a marked increase in their peripheral T lymphocyte response to purified protein derivative (PPD) of tuberculin, which can cause a delayed-type hypersensitivity reaction. Results from the enzyme-linked immunosorbent assay–based IGRA (QuantiFERON-TB Gold In-Tube, Cellestis; Victoria, Australia) blood test for tuberculosis commonly are positive in patients with erythema induratum, again suggesting that that erythema induratum is a hypersensitivity reaction to a systemic infection.

Frequency

United States

Isolated cases of erythema induratum have been reported in the United States.

International

While nodular vasculitis is quite common, particularly in Europe, erythema induratum is rare in Western countries. Erythema induratum is still prevalent in India, Hong Kong, and some areas of South Africa. Erythema induratum was the most common (86%) form of cutaneous tuberculosis (tuberculid) in Hong Kong found between 1993 and 2002³ and was mostly found in women and mostly on the legs. In this period (1993-2002), 127 patients with erythema induratum out of a total of 147 patients with either cutaneous tuberculosis or tuberculids were reported.

Mortality/Morbidity

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.

Sex

Erythema induratum shows female predominance, and lower extremities are the most common sites in both male and female patients; however, it also may occur in other areas.

Age

Erythema induratum most commonly affects women aged 20-30 years. The condition is more common in young women than in other people, but it may occur later in life.

Clinical

History

• A past or present history of tuberculosis at an extracutaneous site occurs in about 50% of patients.
  • Pulmonary tuberculosis is most common.
  • Tuberculous cervical lymphadenitis is the next most common finding.
• Tender, erythematous nodules are present on the lower legs.
  • The nodules have a chronic, recurrent course.
  • The lesions heal with ulcerations or depressed scars.
• Leg edema may be present.
• An infant erythema induratum was reported to occur after BCG vaccination.⁴
• The simultaneous expression of erythema induratum and episcleritis was reported in a 6-year-old girl.⁵
• A variation of erythema induratum, termed nodular tuberculid, with the distinguishing feature of a granulomatous vasculitis occurring at the dermohypodermal junction, has been noted in 5 patients with HIV disease.⁶
• Erythema induratum of Bazin and renal tuberculosis can be associated.⁷
• Silva et al⁸ noted distal painful peripheral neuropathy associated with erythema induratum.

Physical

• Crops of small, tender, erythematous nodules may be observed, as demonstrated in the image below.
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  This patient exhibited tender, erythematous nodules confined to the lower third of the legs.

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  This patient exhibited tender, erythematous nodules confined to the lower third of the legs.

  
  
  • Commons sites are the calves, although the shins are also sometimes involved. Uncommonly, the trunk, buttocks, thighs, and arms can be involved.
  • The nodules are concentrated on the lower third of the legs, especially around the ankles.
  • Lesions may ulcerate with bluish borders, which may be precipitated by cold weather. These irregular and shallow ulceration can result in permanent scarring and hyperpigmentation of the lesions.
  • In 2007, Ramdial et al⁹ reported on 5 patients with tuberculous epididymo-orchitis. A histopathological evaluation confirmed papulonecrotic tuberculids in 4 patients and erythema induratum in 2 patients. Most patients responded to appropriate antibiotics. The researchers concluded that tuberculids incite a sentinel cutaneous manifestation of visceral tuberculosis and help identify occult or asymptomatic tuberculous epididymo-orchitis, as the underlying cause of tuberculids.
  • Sughimoto et al¹⁰ described a patient with aortic valvular lesions of tuberculosis that manifest at the same time as erythema induratum, with granulomatous changes being demonstrated by the aortic valve pathology.

Causes

Erythema induratum/nodular vasculitis complex is a multifactorial disorder. M tuberculosis and delayed-type hypersensitivity are considered etiologic factors for erythema induratum of Bazin type. Recently, hepatitis C virus has been suggested, but a direct relationship remains unclear.

• M tuberculosis is the cause of erythema induratum.
• The cause is unknown in cases of nodular vasculitis with a negative tuberculin skin test reaction.
• Atypical erythema induratum Bazin with tuberculous osteomyelitis has been reported, suggesting that boney changes can be detected clinically.¹¹

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