Erythema Nodosum: An Atypical Presentation of Abdominal Tuberculosis

Abstract

Background & Aims: Erythema nodosum (EN) is a reaction pattern to infection and sometimes to drugs. Histological features suggest that this is an immunological reaction with immune complex deposition within the dermal vessels. Our case is a rare example where EN is associated with extrapulmonary tuberculosis (TB), suggesting a clear evidence of immunological reaction rather than a primary bacterial event. Case: An 11 years old child presented with complaints of high grade fever, generalized lymphadenopathy, painful nodules over shins and loose stools alternating with constipation since the last 15 days with weight loss. Mild tenderness in right iliac fossa was present. Investigations revealed leucocytosis with raised ESR, strongly positive TST and induced sputum negative for AFB. USG and CECT abdomen showed necrotic lymphnodes with omental and IC junction thickening. Lymph node biopsy revealed caseating granulomas. Patient was started on 4 drug antituberculous therapy (ATT). On discharge marked improvement in symptoms were present. Conclusion: Consider strong possibility of extra pulmonary TB presenting as EN especially in developing countries like India in absence of overt signs of TB. The most important step in the management of EN is the treatment of underlying disorder. ATT should be started presumptively for EN with a positive TST result with or without a positively identified focus of infection.