Erythema Induratum (Nodular Vasculitis) Workup
- Author: Noah S Scheinfeld, JD, MD, FAAD; Chief Editor: William D James, MD more...
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.[22, 23, 24]
The CDC states that interferon-gamma release assays (IGRAs) are whole-blood tests that can aid in diagnosing infection Mycobacterium tuberculosis. Two IGRAs that the FDA has approved and are commercially available in the United States are the QuantiFERON-TB Gold In-Tube test (QFT-GIT) and the T-SPOT. TB test (T-Spot). The QuantiFERON test can confirm the presence of latent tuberculosis in association with erythema induratum. The utility of this test was stressed in a patient with tender ulcerating nodules of the lower extremity, a normal chest radiograph, and biopsy without acid-fast bacilli, but whose QT was positive, leading to the diagnosis of erythema induratum. Additional reports have stressed the utility of testing for nodular vasculitis, in particular with the QuantiFERON Gold TB test and the interferon-gamma release assay.
Test for hepatitis.
Chest radiography may be performed. Search for evidence of active or previous infection.
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.
Some patients are highly sensitive to tuberculin PPD. Patients should be tested with a 1:10,000 dilution Mantoux test, as demonstrated in the image below.
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.
Findings consist of a mixed septal and lobular granulomatous panniculitis with neutrophilic vasculitis, as demonstrated in the photomicrographs below.
Caseationlike necrosis may also be seen in erythema induratum. 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).
Sequra et al, in a study of 101 cases of erythema induratum, found that erythema induratum had a variety of presentations of vasculitis and that in approximately 10% of cases, clinicopathologic patterns of vasculitis in erythema induratum could not be demonstrated. The location of the erythema induratum–vasculitis in this series of patients, in descending order, was as follows:
Small venules of the fat lobule
Both the venules of the fat lobule and veins of the connective-tissue septa
Only veins contained in connective-tissue septa
Veins and arteries contained in venules of the fat lobule and in the connective-tissue septa
Connective-tissue septa veins and arteries
Stressing the fact that the histology of erythema induratum has a range of presentations and can be a diagnosis of exclusion, Maharaja et al examined 43 cases of erythematous tender nodules, usually occurring on extremities. In 58.5% of cases, a single clinical diagnosis was made, with the remaining cases garnering more than one diagnosis being considered. Fifty-one percent of cases had histological findings concordant with the clinical diagnosis, but 14% had discordant findings and 35% were left undecided.
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].