Erythema nodosum

Erythema nodosum (synonym: erythema nodosa) is a syndrome based on allergic or granulomatous inflammation of the subcutaneous tissue. The disease belongs to the vasculitis group. Erythema nodosum is a polyetiological form of deep vasculitis.

Erythema nodosum is an independent form of panniculitis, which is characterized by the formation of red or purple palpable subcutaneous nodes on the legs and sometimes in other areas. Often develops in the presence of systemic disease, especially with streptococcal infections, sarcoidosis and tuberculosis.

[1], [2], [3], [4]

What causes erythema nodosum?

Erythema nodosum most often develops in women aged 20-30, but is also possible at any age. The etiology is unknown, but a link with other diseases is suspected: streptococcal infection (especially in children), sarcoidosis, and tuberculosis. Other possible trigger mechanisms are bacterial infections (Yersinia, Salmonella, mycoplasma, chlamydia, leprosy, venereal lymphogranuloma), fungal infections (coccidioidosis, blastomycosis, histoplasmosis) and viral infections (Epstein-Barr, hepatitis B); the use of drugs (sulfonamides, iodides, bromides, oral contraceptives); inflammatory bowel disease; malignant neoplasms, pregnancy. 1/3 of the cases are idiopathic.

The cause of erythema nodosum is primary tuberculosis, leprosy, yersiniosis, lymphogranuloma venerealis and other infections. Described the occurrence of the disease after taking drugs containing a sulfa group, contraceptives. In half of the patients, the cause of the disease cannot be identified. In the pathogenesis of the disease, the hyperergic reaction of the body is marked in infectious agents and drugs. It develops in many acute and chronic, mainly infectious, diseases (tonsillitis, viral, yersiniosis infections, tuberculosis, leprosy, rheumatism, sarcoidosis, etc.), drug intolerance (iodine preparations, bromine, sulfonamides), some system lymphoproliferative diseases (leukemia, Hodgkin's disease, etc.), malignant neoplasms of internal organs (hypernefroid cancer).

Pathomorphology of erythema nodosum

The vessels of the subcutaneous tissue are mainly affected - small arteries, arterioles, venules and capillaries. In the dermis, changes are less pronounced, manifested only by small perivascular infiltrates. In fresh lesions, accumulations of lymphocytes and a different number of neutrophil granulospas appear between the segments of fat cells. Places can be seen more massive infiltrates lymphohistiocytic character mixed with eosinophilic granulocytes. Capillary, destructive proliferative arteriolitis and venulitis are noted. In larger vessels, along with dystrophic changes of the endothelium, they are infiltrated with inflammatory elements, and therefore some authors believe that vasculitis with primary changes in the vessels lies at the base of the skin lesion in this disease. In old cells, neutrophilic granulocytes, as a rule, are absent, granulation changes with the presence of foreign cells predominate. The presence of small histiocytic nodules located radially around the central crack is characteristic of this disease. Sometimes these nodules are riddled with neutrophilic granulocytes.

Histogenesis of erythema nodosum is little studied. Despite the undoubted association of the disease with a large variety of infectious, inflammatory and neoplastic processes, in many cases it is not possible to identify the etiological factor. In some patients, circulating immune complexes, an increased content of IgG, IgM and C3-complement component are detected in the blood.

[5], [6], [7], [8], [9], [10], [11]

Gistopathology

Histologically, the substrate of erythema nodosum is a perivascular infiltration consisting of lymphocytes, neutrophils, a large number of histiocytes, endothelial proliferation of the saphenous veins, capillary arteriole, dermis edema due to increased vascular membrane permeability, acute nodular dermopoderitis.

[12], [13], [14]

Symptoms of Erythema nodosum

Erythema nodosum is characterized by the formation of erythematous soft plaques and nodes, which is accompanied by fever, general malaise and arthralgia.

Rash type of erythema nodosum is one of the main manifestations of Sweet syndrome (acute febrile neutrophilic dermatosis), characterized, in addition, high temperature, neutrophilic leukocytosis, arthralgia, the presence of other polymorphic eruptions (vesicular-pustular, bulle, multiforme ecnemic erythemic erythemic eruptions, polymorphic eruptions (vesicular-pustular, bulle-like, multiformal ecnemic erythemic erythematosus erythematosus). Plaque, ulcers), located mainly on the face, neck, limbs, the development of which attaches importance to immunocomplex vasculitis. There are acute and chronic erythema nodosum. Acute nodular erythema usually occurs on the background of fever, malaise, manifests rapidly developing, often multiple, rather large dermohypodermal nodes of oval shape, hemispherical shape, slightly elevated above the surrounding skin, painful on palpation. Their boundaries are fuzzy. Preferential localization - the front surface of the legs, knee and ankle joints, rashes can be common, The skin above the nodes is bright pink first, then the color becomes bluish. Characterized by a change in color within a few days according to the type of "bloom" of the bruise - from bright red to yellow-green. Resorption of nodes occurs within 2-3 weeks, less often later; possible relapses.

The acute process is characterized by knobby, dense, painful on palpation hemispheric or flattened lesions. Rashes often appear wavy, localized symmetrically on the extensor surfaces of the legs, less often on the thighs, buttocks, forearms. A few days after the onset, foci begin to regress with a characteristic change of pinkish-livid-red color to a livid-brownish and greenish-yellow type of “bruise bloom”. Element evolution - 1 -2 weeks. Nodes do not merge with each other and do not ulcerate. An outbreak of rash is usually marked in spring and autumn. They are accompanied by common phenomena: fever, chills, joint pain. Erythema nodosum may acquire a chronic migratory character (nodular migrating erythema of Befverstedt).

[15], [16], [17], [18],

Diagnosis of erythema nodosum

The diagnosis of erythema nodosum is determined by clinical manifestations, but other studies should be conducted to determine the causative factors for the development of the disease, such as biopsy, skin tests (purified protein derivative), CBC, chest x-ray, pharyngeal smear analysis. The erythrocyte sedimentation rate is usually increased.

Differentiate the disease should be compacted with erythema Bazena, Montgomery-O'Leary-Barker knotty vasculitis, subacute migrating thrombophlebitis in syphilis, primary skin-covariant tuberculosis, subcutaneous sarcoid Darya Russi, skin neoplasms.

[19], [20], [21], [22], [23], [24]

Treatment of erythema nodosum

Erythema nodosum almost always passes spontaneously. Treatment includes bed rest, a raised limb position, cool compresses, and nonsteroidal anti-inflammatory medications. Potassium iodide, 300-500 mg orally, 3 times a day, is used to reduce inflammation. Systemic glucocorticoids are effective, but they should be used last, since they can worsen the condition of the underlying disease. If the underlying disease is identified, treatment should begin.

Prescribe antibiotics (erythromycin, doxycycline, penicillin, ceporin, kefzol); desensitizing agents; salicylates (aspirin, askofen); vitamins C, B, PP, ascorutin, rutin, flugaline, syncumar, delagil, plaquenil; angioprotectors - komplamin, eskuzan, diprofen, trental; anticoagulants (heparin); nonsteroidal anti-inflammatory drugs (indomethacin, 0.05 g, 3 times a day, voltaren, 0.05 g, 3 times a day, meditol, 0.075 g, 3 times a day, optionally); xantinol nicotinate, 0.15 g, 3 times a day (0.3-g teonicol, 2 times a day); Prednisone 15-30 mg per day (in cases of insufficient effectiveness of therapy, with the progression of the process). Carry out the rehabilitation of foci of infection. Locally prescribed dry heat, UHF, UV, compresses with a 10% solution of ichthyol.