Campylobacter jejuni Gastroenteritis Complicated by Erythema Nodosum

Abstract

Purpose: A 24 year-old female patient with recent history of Campylobacter jejuni gastroenteritis presented with new-onset lesions on her lower extremities and various systemic complaints. Ten days prior, she was treated with azithromycin for levaquin-resistant C. jejuni gastroenteritis, mostly resolving her symptoms of diarrhea and abdominal pain. Now she presented with mild weight loss, chills, and fatigue. Her physical exam was notable for two erythematous plaques on her right lower extremity immediately distal to the knee as well as an area of rubor and warmth at the pretibial foot margin measuring 5cm in the largest diameter. She was started on a trial of Align, a low Fermentable, Oligo-, Di-, Mono-saccharides and Polyols (FODMAPs) diet, and dermatology was consulted. Skin biopsy of the ruborous area suggested erythema nodosum (EN). Expectant management was pursued and the skin lesions completely resolved. EN is a cutaneous reaction that causes erythematous, warm, and tender raised plaques to appear, often bilaterally.1 Treatment is mostly supportive utilizing non-steroidal anti-inflammatory drugs (NSAIDs) to decrease inflammation. The etiology for EN is broad, and though EN has been linked with some varieties of gastroenteritis, it is very rarely associated with Campylobacter gastroenteritis. Literature from 1982 described an outbreak of C. jejuni affecting over half of 780 students within the same institution that produced no occurrences of EN.2 However, individual case reports of EN following C. jejuni gastroenteritis were described in 1980,3 1982,4 1990,5 and 2010.6 These isolated cases demonstrate the rarity of this dermatologic manifestation following C. jejuni, but also suggest their association is a worthwhile relationship to appreciate in the differential of gastroenteritis. Our patient's unique presentation of C. jejuni EN was fortunately identified and treated. While difficult to propose an exact etiology, it is wise to consider EN in the dermatologic changes that occur following gastroenteritis; such awareness can prevent unnecessary costs, treatment, and hospitalization.