Erythema Induratum (Nodular Vasculitis)
- Author: Noah S Scheinfeld, JD, MD, FAAD; Chief Editor: William D James, MD more...
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.
Motswaledi and Schulz 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.
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.
Isolated cases of erythema induratum have been reported in the United States.
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 2002 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.
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.
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.
Fernandes SS, Carvalho J, Leite S, et al. Erythema induratum and chronic hepatitis C infection. J Clin Virol. 2009 Apr. 44(4):333-6. [Medline].
Motswaledi HM, Schulz EJ. Superficial thrombophlebitic tuberculide. Int J Dermatol. 2006 Nov. 45(11):1337-40. [Medline].
Ho CK, Ho MH, Chong LY. Cutaneous tuberculosis in Hong Kong: an update. Hong Kong Med J. 2006 Aug. 12(4):272-7. [Medline].
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 Mar-Apr. 31(2):134-9. [Medline]. [Full Text].
Inoue T, Fukumoto T, Ansai S, Kimura T. Erythema induratum of Bazin in an infant after Bacille Calmette-Guerin vaccination. J Dermatol. 2006 Apr. 33(4):268-72. [Medline].
Leahy TR, Downey P, Ramsay B, Philip RK. Erythema induratum of Bazin and episcleritis in a 6 year old girl. Arch Dis Child. 2005 Nov. 90(11):1132. [Medline].
Friedman PC, Husain S, Grossman ME. Nodular tuberculid in a patient with HIV. J Am Acad Dermatol. 2005 Aug. 53(2 Suppl 1):S154-6. [Medline].
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. 2004 Sep-Oct. 46(5):295-8. [Medline].
Kim GW, Park HJ, Kim HS, Chin HW, Kim SH, Ko HC, et al. Simultaneous Occurrence of Papulonecrotic Tuberculid and Erythema Induratum in a Patient with Pulmonary Tuberculosis. Pediatr Dermatol. 2012 Apr 4. [Medline].
Misago N, Narisawa Y. Erythema induratum (nodular vasculitis) associated with Crohns disease: a rare type of metastatic Crohns disease. Am J Dermatopathol. 2012 May. 34:325-9. [Medline].
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. 2006 Dec. 13(12):e5-6. [Medline].
Zakeri K, Oganesyan G, Lee RA, Lillis JV. Erythema induratum of Bazin presenting as peripheral neuropathy. Cutis. 2015 Sep. 96 (3):E1-4. [Medline].
Sharon V, Goodarzi H, Chambers CJ, Fung MA, Armstrong AW. Erythema induratum of Bazin. Dermatol Online J. 2010 Apr 15. 16(4):1. [Medline].
Brandão Neto RA, Carvalho JF. Erythema induratum of Bazin associated with Addison's disease: first description. Sao Paulo Med J. 2012. 130:405-8. [Medline].
Park SB, Chang IK, Im M, Lee Y, Kim CD, Seo YJ, et al. Nodular Vasculitis That Developed during Etanercept (Enbrel) Treatment in a Patient with Psoriasis. Ann Dermatol. 2015 Oct. 27 (5):605-7. [Medline].
Teramura K, Fujimoto N, Nakanishi G, Shigeta M, Tanaka T. Disseminated erythema induratum of Bazin. Eur J Dermatol. 2014 Oct 21. [Medline].
Ramdial PK, Calonje E, Sydney C, Subrayen S, Meyiwa PS, Aboobaker J. Tuberculids as sentinel lesions of tuberculous epididymo-orchitis. J Cutan Pathol. 2007 Nov. 34(11):830-6. [Medline].
Sughimoto K, Nakano K, Gomi A, et al. Aortic valve stenosis associated with Bazin's disease. J Heart Valve Dis. 2007 Mar. 16(2):212-3. [Medline].
Degonda Halter M, Nebiker P, Hug B, Oberholzer M, Fluckiger U, Bassetti S. [Atypical erythema induratum Bazin with tuberculous osteomyelitis]. Internist (Berl). 2006 Aug. 47(8):853-6. [Medline].
Park SH, Chae JK, Kim EJ, Park K. A case of panniculitis caused by Mycobacterium massiliense mimicking erythema induratum. Br J Dermatol. 2015 Jul. 173 (1):235-8. [Medline].
Choy B, Chou S, Anforth R, Fernández-Peñas P. Panniculitis in patients treated with BRAF inhibitors: a case series. Am J Dermatopathol. 2014 Jun. 36(6):493-7. [Medline].
Jacinto SS, Nograles KB. Erythema induratum of bazin: role of polymerase chain reaction in diagnosis. Int J Dermatol. 2003 May. 42(5):380-1. [Medline].
Chen YH, Yan JJ, Chao SC, Lee JY. Erythema induratum: a clinicopathologic and polymerase chain reaction study. J Formos Med Assoc. 2001 Apr. 100(4):244-9. [Medline].
Schneider JW, Jordaan HF, Geiger DH, Victor T, Van Helden PD, Rossouw DJ. Erythema induratum of Bazin. A clinicopathological study of 20 cases and detection of Mycobacterium tuberculosis DNA in skin lesions by polymerase chain reaction. Am J Dermatopathol. 1995 Aug. 17(4):350-6. [Medline].
Center for Disease Control and Prevention. Fact Sheet: Testing and Diagnosis. Tuberculosis (TB). Available at http://www.cdc.gov/tb/publications/factsheets/testing/igra.htm. Accessed: January 30, 2013.
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. 2007 Dec. 157(6):1293-4. [Medline].
Sim JH, Whang KU. Application of the QuantiFERON®-TB Gold test in Erythema Induratum. J Dermatolog Treat. 2012 Sep 19. [Medline].
Sim JH, Whang KU. Application of the QuantiFERON®-TB Gold test in erythema induratum. J Dermatolog Treat. 2014 Jun. 25(3):260-3. [Medline].
Prajapati V, Steed M, Grewal P, Mahmood MN, Verma G, Brassard A. Erythema induratum: case series illustrating the utility of the interferon-? release assay in determining the association with tuberculosis. J Cutan Med Surg. 2013 Oct. 17 Suppl 1:S6-S11. [Medline].
Segura S, Pujol RM, Trindade F, Requena L. Vasculitis in erythema induratum of Bazin: a histopathologic study of 101 biopsy specimens from 86 patients. J Am Acad Dermatol. 2008 Nov. 59(5):839-51. [Medline].
Maharaja K, Khandpur S, Ramam M, Singh MK, Kumar U, Sharma VK. A study of the clinico-histopathological features of erythematous tender nodules predominantly involving the extremities. Indian J Dermatol Venereol Leprol. 2014 May-Jun;. 80(3):235-42. [Medline].
Gilchrist H, Patterson JW. Erythema nodosum and erythema induratum (nodular vasculitis): diagnosis and management. Dermatol Ther. 2010 Jul. 23(4):320-7. [Medline].