Erythema Induratum Of Bazin Research Articles

Erythema Induratum of Bazin: A Rare Finding in an Old Woman with Subcutaneous Nodules in the Lower Limbs

Erythema induratum of Bazin (EIB) is a chronic nodular eruption that frequently occurs on lower legs of young or middle-aged women. The clinical manifestations of EIB revealed various dermatological disorders that can be easily leads to misdiagnosis. We report a case of a 50-year-old woman who initially presented with EIB. The histopathological specimen was collected from her medial aspect of let leg. The epidermis is unremarkable. The dermis shows fibro fatty tissue, skin adnexae and foci of granuloma with Langhans type of giant cells and some lymphocytic infiltration in the deep dermis which was suggestive of erythema induratum. Her lesions responded to antitubercular therapy (ATT). This case study may help extend the therapeutic regimens for cutaneous tuberculosis.
 CBMJ 2023 January: Vol. 12 No. 01 P: 121-123

A rare cutaneous tuberculosis form, erythema induratum of Bazin: 6 years’ experience

Erythema induratum of Bazin (EIB) is a rare tuberculid form characterized by hypersensitivity to Mycobacterium tuberculosis antigens. There are a few case series related to EIB in the literature. We evaluated the demographic, clinical, treatment, and follow-up characteristics of patients diagnosed with EIB. Demographic, clinical, histopathologic, and imaging findings as well as treatment and follow-up properties were evaluated in 22 patients retrospectively diagnosed with EIB between January 2013 and December 2018. Of the 22 patients,90.9% were female and 9.1% were male. The mean age was 57.2 ± 12.9 years. Ten of the patients had a history of contact with tuberculosis, and one had a history of active pulmonary tuberculosis. The purified protein derivate (PPD) test average was 18.1 mm. The lesions were located in the lower extremity in all patients and in the upper extremity in 31.8% of patients. Histopathologically, 22.7% had vasculitis, 27.3% were treated with four tuberculosis drugs, and 72.7% were followed without tuberculosis treatment. Treatment was continued for two patients, and 75.0% of the patients treated with a four-drug regimen recovered. Relapse was observed in one of the patients after 36 months. The recovery rate was found to be 87.5% in patients that did not receive tuberculosis treatment, and there were no relapses in the follow-up. EIB's etiopathogenesis is unknown. In total, 75.0% of the patients receiving tuberculosis treatment and 87.5% of the patients without tuberculosis treatment recovered in our study. The role of tuberculous therapy in the management of EIB is controversial. The selection of appropriate treatment for EIB continues to be an area of debate, and further studies are needed.

Cutaneous tuberculosis in Rio de Janeiro, Brazil: description of a series of 75 cases.

Brazil is one of the highest tuberculosis (TB) burden countries of the world. Cutaneous tuberculosis (CTB) is a rare form of extrapulmonary manifestation of tuberculosis. This study aimed to describe the clinico-evolutive, laboratory and therapeutic aspects of CTB cases among patients from a cohort with TB in Rio de Janeiro, Brazil. Cases of diagnosed CTB with microbiologic confirmation or clinical response to anti-tuberculous treatment associated with positive smear or histopathological findings between the years 2000 and 2016 were selected. Seventy-five patients with CTB were included, most were women (58.7%) with a median age of 42years. CTB diagnosis was based on culture in only 42.7% of the cases. Scrofuloderma represented 50.7% of the cases, followed by erythema induratum of Bazin (EIB) (18.7%), tuberculous gumma (13.3%), lupus vulgaris (8%), TB verrucosa cutis (4%), orificial TB (2.7%) and associated forms (2.7%). Other TB presentations were pulmonary (22.7%), mammary (6.6%) and osteoarticular (4%). All patients who completed the treatment (97.3%) had their lesions healed. Only two patients (2.6%) needed to change the therapy due to adverse reactions. Fifty percent of EIB patients presented recurrence. These data highlight the diversity of CTB presentations and the importance of the skin to assist in early identification and treatment of TB. More studies are necessary to improve the knowledge on EIB for a better approach towards these patients, mainly in cases of recurrence.

Recurrent Erythema Nodosum as a Warning of Tuberculous Lymphadenitis

An 84-year-old woman with a history of hypertension and cerebral infarction was referred to the hospital with general malaise and recurrent painful erythema nodosum (EN) on her legs. The EN recurred and resolved within a few weeks several times during the preceding 6 months. Physical examination revealed multiple thumb-sized painful EN lesions on her lower legs, mainly on the posterior surface (Figure A [arrow]). In addition, the right axillary superficial lymph nodes were palpable. Pathological findings of EN were not specific or diagnostic. On the other hand, pathological findings of the right axillary lymph nodes revealed epithelioid granuloma with caseous necrosis and Langhans giant cells (Figure, B [arrows]). Ziehl-Neelsen stain identified organisms that are acid fast (Figure C [arrow]). The interferon-γ release assay (T spot) yielded positive results. Based on these results, the patient was diagnosed as having tuberculous lymphadenitis and associated erythema induratum of Bazin (EIB). She had complete remission of the tuberculous lymphadenitis and EIB after 4-drug antituberculosis therapy. The EIB has not recurred 4 years after the therapy. Erythema induratum of Bazin is a nodular tuberculid, which denotes a skin immunologic reaction to the presence of occult tuberculosis elsewhere in the body. Treatment of EIB does not differ from the conventional therapy for tuberculosis of primary lesion, and the favorable treatment outcome in EN on using antituberculosis therapy reinforces the diagnosis of EIB. Physicians should consider extrapulmonary tuberculosis when patients show characteristic recurrence of EN on the legs.

Cutaneous tuberculosis in China - A multicentre retrospective study of cases diagnosed between 1957 and 2013.

China has one of the largest populations with tuberculosis worldwide. Cutaneous tuberculosis (CTB) is a rare manifestation of mycobacterial infection. Although CTB is well described, it is important to periodically revisit the prevailing clinical and epidemiological features in most populated countries such as China, India, and Indonesia, where tuberculosis is still a major health problem. This retrospective study aimed to re-evaluate the CTB cases in China in the past 50 years to obtain a comprehensive insight into this multiplex entity. Cases of diagnosed CTB with confirmed histology from four large medical centres in central China between 1957 and 2013 were collected and analysed, including demographic data, clinical manifestations and pathological findings. Of the 1194 cases enrolled, there were 666 (55.78%) and 528 cases (44.22%) of true CTB and tuberculids, respectively. Erythema induratum of Bazin (EIB) was the most common CTB (35.8%), followed by lupus vulgaris (LV, 32.7%), tuberculosis verrucosa cutis (18.9%), papulonecrotic tuberculid (8.0%), scrofuloderma (2.8%), tuberculosis cutis ulcerosa (1.3%), penile tuberculids (0.4%), and lichen scrofulosorum (0.1%). EIB was the predominant tuberculid (80.87%), while LV the predominant true CTB (58.7%). The number of diagnosed CTB showed a decreasing trend in the 1960s and 1970s, then increased again, and peaked in the 1990s. Cutaneous tuberculosis is still a common problem in China. Chronologic changes in CTB cases reported in China over the past 50 years may reflect the prevalence transition of overall tuberculosis. CTB has diverse clinical presentations, and each subtype is characterized by specific gender predilection, duration, age, clinic and pathological findings.

Erythema Induratum of Bazin: A Rare Presentation of Tuberculosis

Erythema induratum of bazin (EIB) is a hypersensitivity reaction to Mycobacterium tuberculosis infection. The diagnosis can be difficult because tubercle bacilli are usually not found in smears or cultures of lesions. This study reports on a case of EIB in a 13-year-old female, who presented multiple tender nodules on her lower extremities. Biopsy of the nodule revealed histopathologic changes compatible with erythema induratum. QuantiFERON test was positive. The patient received a 6-month duration of anti-tuberculosis treatment. The lesions disappeared during therapy, and no pigmentation was observed at the end of treatment. After a year of follow up, there was no recurrence of the disease.

Application of IFN‐γ releasing assay for the diagnosis of erythema induratum of Bazin

Erythema induratum of Bazin (EIB) is regarded to be a hypersensitive reaction to the concomitant tuberculosis. Recently, interferon-γ releasing assay (IGRA) has been focused as a promising tool in the diagnosis of latent tuberculosis. However, there has been no large scale study to investigate the usefulness of IGRA in the diagnosis of EIB. To evaluate the diagnostic performance for the detection of EIB. We retrospectively reviewed medical records of all patients with EIB, in the Department of Dermatology, at the Seoul National University Hospital, between April 2009 and September 2011. We analysed clinicopathological features, responses to IGRA and the treatment courses. In addition, we compared positive rate of IGRA in patients with other diseases during the same period. All of the 22 patients demonstrated a positive response to IGRA (100%) and showed a good response to anti-tuberculosis treatment. In contrast, positive rate was 63.64% and 66.67% in patients with psoriasis and other vasculitis respectively. We observed complete resolution of skin lesions in 14 patients. Partial resolution was attained in one patient and the other seven patients are currently on the medication and are showing good responses. We verified that IGRA has an excellent diagnostic performance in EIB, through this observational study. It is strongly suggested that if EIB is clinicopathologically suspected, IGRA should be performed.

Erythema induratum of Bazin in an infant after Bacille Calmette‐Guerin vaccination

We report the first case of erythema induratum of Bazin (EIB) after Bacille Calmette-Guerin (BCG) vaccination in an infant. The patient developed recurrent multiple erythematous and subcutaneous nodules on his legs 2 months after a BCG vaccination. He had no other symptoms or family history of tuberculosis (TB). Histopathological findings revealed a granulomatous lobular panniculitis. EIB often appears as a chronic, nodular eruptions that frequently occur on the lower legs of females with tuberculin hypersensitivity. To date, only a few cases of infants with EIB have been reported. There have been no clinical reports of EIB after BCG vaccination. Our case suggests that Mycobacterium bovis in the BCG vaccination may have caused EIB.

Nodular Tuberculid: A Report of Four Patients

The tuberculids are hypersensitivity reactions to Mycobacterium tuberculosis (MTB) and include papulonecrotic tuberculid (PNT), lichen scrofulosorum, erythema induratum of Bazin (EIB), and phlebitic tuberculid. Papulonecrotic tuberculid displays papulonecrotic lesions mostly on the extensor surfaces of the limbs. Histopathology shows necrosis, granulomatous inflammation (GI), and occasionally vasculitis, usually in the superficial dermis. Erythema induratum of Bazin shows nodulo-ulcerative lesions on the posterior aspect of the legs. Histopathology reveals a septolobular panniculitis, necrosis, GI, and vasculitis. The Mantoux test is strongly positive and associated tuberculosis (TB) may be present in both conditions. MTB cannot be demonstrated with a Ziehl-Neelsen (ZN) stain or cultured. The polymerase chain reaction has demonstrated MTB DNA in PNT (50%) and EIB (25%). The tuberculids respond to full anti-TB treatment. We document four patients with nodules on the legs in whom the pathologic changes were situated in the deep dermis and adjacent subcutaneous fat. Nodular tuberculid (NT) is regarded as a suitable term for these lesions. All patients were female. Their ages were 19 months, 12 years, 17 years, and 5 years. All patients presented with nodules on the limbs. These nodules were approximately 1 cm in diameter, dull red or bluish-red, and nontender. Ulceration was not present. The number of nodules varied from a few to many. The Mantoux test was strongly positive in all the patients. Associated pulmonary TB was present in two patients. Histopathology showed GI (n = 4), vasculitis (n = 2), and coagulative necrosis (n = 2). A ZN stain was negative in each case. All patients received anti-TB treatment for 6 months [rifampicin (n = 4), isoniazid (n = 4), pyrazinamide (n = 4), and ethambutol (n = 2)]. At 12 months follow-up, skin and pulmonary lesions had resolved in all. Nodular tuberculid should be distinguished from arthropod bites and papular urticaria, dermal erythema multiforme, evolving vasculitis, evolving folliculitis, and erythema nodosum. Histopathologically NT should be distinguished from other causes of granulomatous vasculitis and GI with or without necrosis. In children with nodules on the limbs unresponsive to routine treatment, skin biopsy should be done to exclude NT. Nodular tuberculid represents a hybrid between PNT and EIB with characteristic clinicopathologic features and should be included in the classification of cutaneous TB.

Detection of Mycobacterium tuberculosis in Erythema Induratum of Bazin Using Polymerase Chain Reaction

Tuberculosis poses a serious diagnostic and therapeutic problem, even in developed countries. As originally described, 1 tuberculids are cutaneous eruptions that result from an abnormally marked host response to the presence of mycobacteria. One such tuberculid is erythema induratum of Bazin (EIB), in which Mycobacterium tuberculosis has recently been detected. 2 Patients and Methods. Sixteen formaldehyde solution— fixed, paraffin-embedded blocks of EIB were collected from 1988 to 1995 ( Table ). 3 As a positive control in all procedures, a paraffin-embedded sample of M tuberculosis as confirmed by mycobacterial culture was included. As a negative control, an acrochordon specimen was included. Reagent controls were also included. DNA was extracted from paraffin-embedded blocks as previously described 4 and analyzed for M tuberculosis DNA by polymerase chain reaction (PCR) using a primer specific for M tuberculosis and M bovis . 5 The methods outlined by Eisenach et al 5 were adhered to stringently with 1

Detection of Mycobacterium tuberculosis in erythema induratum of bazin using polymerase chain reaction

Tuberculosis poses a serious diagnostic and therapeutic problem, even in developed countries. As originally described,¹tuberculids are cutaneous eruptions that result from an abnormally marked host response to the presence of mycobacteria. One such tuberculid is erythema induratum of Bazin (EIB), in which<i>Mycobacterium tuberculosis</i>has recently been detected.² <h3>Patients and Methods.</h3> Sixteen formaldehyde solution— fixed, paraffin-embedded blocks of EIB were collected from 1988 to 1995 (<b>Table</b>).³As a positive control in all procedures, a paraffin-embedded sample of M<i>tuberculosis</i>as confirmed by mycobacterial culture was included. As a negative control, an acrochordon specimen was included. Reagent controls were also included. DNA was extracted from paraffin-embedded blocks as previously described⁴and analyzed for M<i>tuberculosis</i>DNA by polymerase chain reaction (PCR) using a primer specific for M<i>tuberculosis</i>and M<i>bovis</i>.⁵The methods outlined by Eisenach et al⁵were adhered to stringently with 1

Erythema induratum of Bazin. A clinicopathological study of 20 cases and detection of Mycobacterium tuberculosis DNA in skin lesions by polymerase chain reaction.

Erythema induratum of Bazin (EIB) is a chronic, recurring panniculitis that is found predominantly on the legs of women with tuberculin hypersensitivity. A causal relationship between EIB and Mycobacterium tuberculosis remains elusive because of the absence of demonstrable organisms in skin lesions. We reviewed the clinicopathological features of 20 patients (all women) with positive Mantoux tests (1:10,000 dilution) and characteristic skin lesions of EIB that cleared up with combined antituberculous treatment. Histological examination of skin lesions confirmed panniculitis with varying combinations of granulomatous inflammation, primary vasculitis, and necrosis. Sections from 20 formalin-fixed, paraffin-embedded skin biopsies obtained from the 20 patients were submitted for polymerase chain reaction (PCR) using oligonucleotide primers for the detection of a 123-bp DNA fragment specific for the M. tuberculosis complex. M. tuberculosis DNA was identified in five of the 20 biopsies. Meticulous care was taken to prevent contamination as a source of false-positive results. Mycobacterial DNA was absent in all negative controls and in normal skin biopsies from purified protein derivative-positive patients with and without EIB. These results provide direct evidence that mycobacterial components are present in EIB lesions and strongly suggest that M. tuberculosis is involved in the pathogenesis of EIB.