Erythema Nodosum and Hilar Lymphadenopathy

Abstract

Erythema nodosum is generally regarded as a “non-specific inflammatory reaction of the skin to a variety of bacterial, toxic, and chemical agents,” usually associated with an acute febrile illness, and often with joint pains and malaise. Not infrequently erythema nodosum is associated with pulmonary hilar lymphadenopathy; therefore, it must be considered in the differential diagnosis of patients with enlarged hilar shadows. This fact does not seem to be generally known, and since there are obvious practical considerations involved, the authors consider it worthwhile to review the thoracic manifestations of the disease, and briefly to present four cases. Clinical Features.’ In the typical case of erythema nodosum, there is a febrile onset with temperature elevations to 100-102 degrees F., associated with, or followed in a few days by, the appearance of painful nodular erythematous lesions on the shins, and sometimes on the forearms, buttocks, chest and elsewhere. These nodules vary in size from a few millimeters to five or six centimeters in diameter. They are not fluctuant and do not suppurate. The overlying skin is smooth, shiny, and usually a rose-red or purplish-red color or even fiery red. The nodules are often tender and painful. After a few days to several weeks, they slowly subside, leaving brownish pigmented areas which slowly fade. The patient often complains of painful swollen joints during the acute stage of the illness. An interesting and not infrequent finding is cardiac involvement, manIfested by such electrocardiographic changes as prolonged A-V conduction or flattening or inversion of T-waves.2 The heart may appear dilated temporarily by roentgenography, but so far as is known, there is no persistent heart damage. Pathology and Pathogenesis: The skin lesions show dilatation of the capillaries, extravasation of serum, leukocytes and erythrocytes into the surrounding tissues, and later disintegration of the red blood cells which gives the characteristic color of the lesion. The changes are those of a non-specific inflammatory reaction only, regardless of the etiology. The pathogenesis is unknown, though the lesions are thought to represent a peculiar allergic response to various agents. In cases of erythema nodosum with lymphadenopathy associated with sarcoidosis or tuberculosis, the involved lymph nodes show the typical pathology of the underlying disease. The authors have not encountered reports of examinations of the 5Read at the Northwest Regional Meeting of the American College of Chest Physicians, Vancouver, B. C., on November 14, 1952. 328