Tender Erythematous Nodules Research Articles

Split Dose of Prednisolone in the Treatment for Erythema Nodosum Leprosum: A Case Series.

Background Erythema nodosum leprosum (ENL) is an immune complex-mediated reaction that clinically presents as tender erythematous evanescent nodules, mostly associated with systemic symptoms. Oral prednisolone is the drug of choice, with doses ranging from 0.5 to 1 mg/kg. Some cases may develop new lesions and systemic symptoms despite 1 mg/kg prednisolone, and in ideal practice, physicians escalate the prednisolone dose for immediate arrest of inflammation to prevent complications. However, a high dose of prednisolone has more side effects in the long term and causes more immunosuppression. Methods In cases of ENL, those not responding to a conventional once-daily regimen were given a split dose of oral prednisolone instead of increasing the dose. They were followed up for response, and serum cortisol was measured to see for hypothalamic-pituitary-adrenal (HPA) axis suppression. Results Eight cases of ENL (three nodular, three necrotic, one pustular, and one nodulcerative) had a dramatic response to split-dose therapy without any relapse and HPA axis suppression. Conclusion A split-dosing regimen can be a good treatment option in ENL with better control, less steroid dependency, and a lower relapse rate.

Unusual Presentation of Marginal Zone Lymphoma

Primary cutaneous B-cell lymphomas (pcBCLs) are non-Hodgkin lymphomas that present with exclusive cutaneous disease at the time of diagnosis. The lesions may be indolent, subtle, or waxing and waning, making the diagnosis challenging. The ear is an uncommon location, and its frequency of involvement remains unknown. A retrospective analysis of a single patient with primary cutaneous marginal zone lymphoma of the ear. The patient was a 44-year-old male who presented with erythematous tender nodules on the left superior posterior helix. Shave biopsy revealed mixed dermal lymphoid infiltrate with eosinophils and telangiectasias. The patient was diagnosed with angiolymphoid hyperplasia with eosinophilia. Multiple treatment regiments were trialed but failed due to lack of therapeutic response, relapse, and clinical progression. The patient ultimately underwent Mohs surgery with biopsy findings that demonstrated CD-20 positive cells. Evaluation with B-cell histopathology and gene rearrangement studies confirmed the diagnosis of marginal zone lymphoma. This case report shows a unique presentation of marginal zone lymphoma of the ear, initially diagnosed as angiolymphoid hyperplasia with eosinophilia. Our findings demonstrate a relatively rare presentation for this disease and highlight the challenges in diagnosing primary cutaneous marginal zone lymphoma.

Mycobacterium welchii Vaccine Granuloma – A Cautionary Tale

Background: Mycobacterium welchii (Mycobacterium w) vaccine was one of the many strategies used to both treat and prevent coronavirus disease 2019 (COVID-19) infection. We report the results of a retrospective analysis of 15 cases with vaccine-site granulomas after administration of prophylactic Mycobacterium w vaccine as part of a trial for COVID-19 and our experience in managing those cases. Methods: This was a retrospective analysis of 15 patients with vaccine-site granulomas who were given the vaccine as a prophylactic measure as part of a trial with informed consent. Results: The mean average age of cases was 37 and the male-to-female ratio was 1:0.87. All of the patients developed erythematous tender nodules over the injection sites within a month of receiving the inoculations. Mycobacterial cultures and cartridge-based nucleic acid amplification tests yielded negative results. Skin biopsy revealed granulomatous dermatitis with acid-fast bacilli positivity. A diagnosis of noninfective granulomatous dermatitis was made. Treatment started with analgesics and anti-inflammatory agents. Systemic antibiotics were required in 9/15 patients. Patients are being followed up with no reported recurrence till date. Conclusion: The possibility of injection-site granuloma should be taken into the risk–benefit analysis for the administration of Mycobacterium w vaccine and the patients should be counseled as such. Patients with persistent ulceration respond to combinations of doxycycline, ofloxacin, and clarithromycin.

Pain or Weakness? An Immunocompromised Patient Presenting with Inability to Walk

IntroductionErythema nodosum (EN) appears as tender erythematous nodules, mainly on the pretibial areas. The causes are varied including medication side effects, infections, autoimmune conditions, malignancy, and is idiopathic in 50% of cases. The pathophysiology is not completely understood but may involve an immunologic response or hypersensitivity reaction to various stimuli, leading to immune complex deposition in the venules of septae in subcutaneous fat. Case Presentation17-year-old male with right mandible ameloblastoma (positive for BRAF V600E mutation), who was diagnosed in May 2022, and has been semi-compliant with dabrafenib, BRAF V600E mutation kinase inhibitor, for the previous 6 months and was off for about 1 week when he presented with fever, followed by painful rash of extremities, including soles and palms, and ascending weakness with inability to walk, concerning for neurological insult. The rash was confluent, macular patches, non-pruritic, blanching with a needle-like tenderness. We questioned whether the inability to walk was neurological or related to pain. Brain Magnetic Resonance Imaging (MRI) was unremarkable. Extensive infectious disease testing yielded rhinovirus/enterovirus positive Polymerase Chain Reaction (PCR) but was negative for all other pathogens, including Streptococcus A infection. Rheumatologic workup was negative. He was treated with Non-Steroidal Anti-Inflammatory Drugs and triamcinolone cream which provided improvement of rash and presenting symptoms. Skin biopsy showed granulomatous panniculitis compatible with EN. Dabrafenib was discontinued. DiscussionPatient’s initial presentation was concerning for acute onset of ascending weakness in an immunocompromised patient, suggestive of Guillain-Barré syndrome. Muscular strength was difficult to examine upon initial physical exam likely due to patient effort versus experienced symptoms and patient’s need for assistance to ambulate. However, detailed neurological examination and having normal brain MRI led to the conclusion that the acute change was EN-related pain, rather than weakness. After extensive infectious and rheumatological work up, we concluded that the patient’s EN was likely secondary to Dabrafenib use even if adherence was suboptimal. Clinicians should be aware that EN is an adverse reaction which has been reported in relation to Dabrafenib, as evidenced by a retrospective chart review and case report.

Recent-onset erythematous tender plaques and nodules in a child with nephrotic syndrome.

A 10-year-old girl with nephrotic syndrome who was on systemic corticosteroids presented with multiple erythematous tender nodules over her trunk and extremities. Histopathology showed mild lobular panniculitis with needle-shaped crystals. The lesions subsided spontaneously without any sequelae within 3 weeks.

Erythematous tender nodules on the legs with oilyexudate.

This 70-year-old woman presented with multiple tender erythematous nodules on her legs with some breaking down and discharging an oily substance. Histology showed extensive active chronic inflammation of the dermis and lobular panniculitis.

Borderline Lepromatous Leprosy with Severe Erythema Nodosum Leprosum: A Case Report

Background: Leprosy is a chronic granulomatous infectious disease caused by Mycobacterium leprae (M. leprae) that primarily infects Schwann cells in the peripheral nerves, leading to nerve damage and the development of disabilities. In 2018, Indonesia was the third country with the most leprosy cases in the world. Erythema nodosum leprosum (ENL), also known as type II leprosy reaction, is a severe immune-mediated complication of multibacillary leprosy. Purpose: To report a case of borderline lepromatous leprosy with severe ENL. Case: A 49-year-old Balinese man presented with multiple tender erythematous skin nodules all over his body, fever, arthralgia, bilateral cervical lymphadenopathy, and sensory loss for the past week. The acid-fast bacilli bacteriological examination showed a positive result. The patient was diagnosed with borderline lepromatous (BL) leprosy with severe ENL and was treated with multibacillary multidrug therapy (MB MDT), methylprednisolone, and other symptomatic medications. After 1 month of treatment, there was an improvement in skin lesions. The MB-MDT treatment was continued and methylprednisolone was planned to be tapered down gradually. Discussion: Approximately 20-50% of all leprosy patients show leprosy reactions in the course of the disease. The goals of treatment for severe ENL are to control inflammation, reduce pain, treat neuritis to prevent nerve dysfunction and contractures, and prevent recurring ENL. The prognosis of leprosy with ENL reactions depends on the severity of the occurring leprosy reaction; early diagnosis and prompt treatment; and patient compliance with treatment. Conclusion: Early diagnosis and treatment are essential to avoid deformities in leprosy patients.

149 Sweet’s Syndrome: One Center Study of 42 Patients

Sweet’s syndrome (SS) is a rare acute febrile neutrophilic dermatosis characterized by an abrupt onset of fever, arthralgia, neutrophilia, tender erythematous papules, nodules, and plaques. We present a case series of patients seen at the dermatology department of the Ibn Sina University Hospital (Rabat). The goal of our study was to describe the epidemiological, clinical profile and the possible association of the Sweet syndrome in our department. We performed a descriptive retrospective study of 42 Moroccan patients seen between January 2004-January 2020.

Seeing the outside, remember the inside: A rare cutaneous manifestation of pancreatitis

We present a case of a 70 year old man with recurrent abdominal pain for one month, which preceded the onset of erythematous tender nodules over bilateral lower limbs. After full history taking and extensive investigations, he was subsequently found to have chronic pancreatitis with a pancreatic duct stone. Skin biopsy of the nodules showed lobular panniculitis and in the setting of high serum amylase, he was diagnosed to have pancreatic panniculitis. We highlight the clinical and histopathological findings of this rare cutaneous manifestation of pancreatitis.

Sweet's Syndrome

Background: Sweet's syndrome (SS) is a classical representative of neutrophilic dermatosis characterized by the abrupt onset of fever, erythematous tender plaques and nodules on exposed parts, and histopathological reaction in response to different external and internal stimuli. Objectives: The aim of this study was to assess the clinical, epidemiological, histological features and therapeutic outcomes of SS. Materials and Methods: A retrospective study of all patients diagnosed with SS over a 4-year period (2016–2020) was conducted. Results: Over a period of 4 years, a total number of cases of SS were 16. Female patients were predominant around 13 (81.25%), and male patients were 3 (18.75%). The most common site affected was face in 87.5% (14), followed by upper limb in 50% (8) and lower limb in 25% (4). Among the systemic manifestations, fever was there in all cases. The associated causes were infectious conditions in 6 (37.5%) cases, among which five cases were upper respiratory tract infection, hematological malignancy in three cases, one case with solid tumors, one case was associated with acquired cutis laxa (Marshall' s syndrome), one was drug induced (diclofenac sodium), one case was pregnancy associated, and other three cases were idiopathic. Conclusion: SS can be diagnosed based on clinical and laboratory findings. In all atypical and recurrent SS cases, thorough evaluation for malignancy is essential. Dapsone can be considered a concomitant therapy along with steroids and also a steroid-sparing agent.

Autologous Fat Transfer in Lupus Panniculitis Facial Lipoatrophy.

Lupus panniculitis (LP) often presents with tender nodules and intermittent ulcers that then heal with scarring and lipoatrophy. The current mainstay of treatment is medical treatment. Research regarding the treatment of lipoatrophy from LP with autologous fat grafting is limited. We would like to share our experience in this rare case, which was treated with autologous fat transfer. A 48-year-old female presented with erythematous plaque, tender nodules, and ulcers following by a depression of the lesion at the left temporal area. The patient also had indurated erythematous plaque at her left cheek. Both lesions were aggravated by sunlight exposure. After several investigations, she was diagnosed as LP with secondary lipoatrophy and tumid lupus erythematosus at her left temporal and left cheek, respectively. She received antimalarial drug and topical steroids. The patient underwent two sessions of autologous fat transfer. She was satisfied with the volume and contour improvement in the scar following the injection of 8 and 3.7 mL of fat. Furthermore, the patient reported the remission of tender nodules and ulcers since the first fat graft injection. In conclusion, the autologous fat transfer is a simple and effective treatment for lipoatrophy and scar secondary to LP with promising results.

VASCULITIS AND RENOVASCULAR HYPERTENSION – A CASE REPORT

Objective: Vasculitides are a group of rare, systemic diseases that induce inflammatory reactions in blood vessels, causing a reduction of blood flow and ischemia. In the kidney, luminal narrowing reduces blood flow and activates the renin-angiotensin-aldosterone system, causing renovascular hypertension. Design and method: Clinical case report. Results: A 47-year-old male with previous intestinal tuberculosis and hypertension diagnosed two years prior (blood pressure around 220/110 mmHg) was referred to our Hypertension Clinic. He reported self-limited episodes of lumbar pain, tender erythematous nodules in the shins and arthralgias. His mean office blood pressure was 203/118 mmHg, confirmed in home blood pressure monitoring, without medication. He had left ventricular concentric hypertrophy and chronic kidney disease (eGFR 66 mL/min/1.73m2) with albuminuria (561 mg/24 h). Verapamil and clonidine were prescribed to search for secondary hypertension but he missed the following appointment. A few months later he was admitted to the Intensive Care Unit due to a hypertensive emergency, with acute kidney failure and a large peri-renal hematoma. A CT scan and an angiography showed bilateral renal scarring, intrarenal pseudoaneurysms and small irregularities in the renal arteries. The immunologic panel was negative. A PET scan showed a slight enhancement of the aorta walls and common carotid arteries and the diagnosis of large-vessel vasculitis was established. He was discharged with high-dose corticosteroids and lisinopril and returned to our Hypertension Clinic. His blood pressure remained uncontrolled despite full-dose amlodipine, chlorthalidone and nebivolol; lisinopril was stopped due to worsening kidney function. Due to doubts on the diagnosis, the CT scan was repeated, now showing also irregularities in the common hepatic artery and mesenteric artery, suggesting a medium-vessel vasculitis, namely polyarteritis nodosa, and cyclophosphamide was started. His blood pressure is now controlled with lisinopril 2.5 mg, amlodipine 10 mg bid, furosemide 40 mg bid, nebivolol 5 mg and clonidine 0,15 mg tid and his kidney function is stable. Conclusions: Renovascular hypertension is responsible for less than 1% of all cases of hypertension and, when present, it is usually caused by atherosclerotic disease or fibromuscular dysplasia. However, in more infrequent cases, an inflammatory systemic disease may be present and must be considered.

Sequential occurrence of recurrent Sweet syndrome and erythema nodosum without an underlying secondary cause: a case report

BackgroundSweet syndrome is a rare cause of acute fever and painful erythematous skin plaques. Erythema nodosum is acute or chronic tender erythematous skin nodules of bilateral shins. The concurrent presence of both dermatoses is rare but reported in the literature. There are no reported cases of recurrent and sequential Sweet syndrome and erythema nodosum without an underlying secondary cause.Case presentationWe report the case of a 64-year-old Asian woman, who had possible Sweet syndrome 12 years ago and biopsy-proven erythema nodosum 5 years ago, presenting with an acute episode of Sweet syndrome. Extensive investigations did not reveal any underlying secondary cause.ConclusionsRecurrent Sweet syndrome and sequential presence with erythema nodosum raises suspicion if Sweet syndrome and erythema nodosum are different presentations of one disease, which warrants further study. This case proves that recurrent Sweet syndrome and erythema nodosum can occur in healthy individuals without an underlying malignancy or secondary cause.

VEXAS syndrome (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) for the dermatologist

In 2020, Beck etal1 described a novel adult autoinflammatory syndrome entitled VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic), a newly-discovered disorder that connected previously unrelated inflammatory syndromes and a prototype for a new class of hematoinflammatory diseases.2 Eighty-nine percent of published cases have documented skin involvement, but despite the high incidence and diagnostic accessibility of skin manifestations, there has been little focus on the dermatological features of VEXAS syndrome thus far. A PubMed search of all published case reports of VEXAS syndrome to date was performed, with inclusion of all cases confirmed by genetic sequencing, and this review summarizes the reported dermatological signs. There have already been 141 confirmed published cases since original publication, 126 of which had documented cutaneous signs.1-34 A wide range of skin presentations are reported, including Sweet-like urticated and tender erythematous nodules, cartilaginous involvement with chondritis, cutaneous vasculitis, and periorbital angiodema.1-34 Many patients had been diagnosed with Sweet syndrome, relapsing polychondritis, polyarteritis nodosa, or erythema nodosum.1-34 Hallmarks of skin histopathology are a neutrophilic dermatosis with coexisting or exclusive leukocytoclastic vasculitis.1 The new classification therefore helps link previously disparate inflammatory skin conditions into a unifying pathophysiological pathway.

SWEET SYNDROME WITH PULMONARY INVOLVEMENT

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sweet syndrome (acute neutrophilic dermatosis) typically presents with cutaneous lesions, fever, and arthralgia. Sweet syndrome with pulmonary involvement is rare and to our knowledge, only 40 cases have been reported in the literature. In this case, we will highlight the clinical and radiographic findings seen in Sweet syndrome with pulmonary involvement. CASE PRESENTATION: A 58-year-old male with past medical history of GERD presented to the ED with worsening SOB and a nonproductive cough. He endorsed recent completion of Levofloxacin therapy for presumed pneumonia. Vital signs were notable for fever of 39º C. Patient was tachypneic and required 3L NC for O2 saturations > 92%. PE revealed decreased LLL sounds as well as erythematous nodules noted on bilateral lower extremities. CBC showed elevated WBC of 18.2. CMP and urinalysis were within normal limits. CT Chest showed bilateral ground glass opacities and minimal pleural effusions. IV Vancomycin and Zosyn were initiated for community acquired pneumonia coverage, however patient continued to spike fevers. Blood and urine cultures remained negative. On day eight of admission, bronchoscopy was performed. BAL and transbronchial biopsy showed extensive neutrophilic infiltrate. Skin biopsy also showed a dense dermal infiltrate composed of neutrophils. Four days after the biopsy, patient developed acute hypoxic respiratory failure requiring ICU admission for intubation. CT Chest showed worsening bilateral pleural effusions and ground glass opacities. Intravenous methylprednisolone was started with rapid improvement in patient's respiratory and cutaneous symptoms. Patient was eventually transitioned to oral prednisone. DISCUSSION: In this case, we present a patient with histopathological and radiographic findings of Sweet syndrome with pulmonary involvement. Our patient fulfills two major and at least two minor criteria of Sweet syndrome including abrupt onset of tender erythematous nodules and a dense dermal neutrophilic infiltrate without leukocytoclastic vasculitis on histology. Minor criteria included fever > 38º C, elevated ESR, neutrophilia, and a dramatic response to treatment with steroids. Prompt transbronchial and skin biopsies in combination with an excellent response to corticosteroid therapy confirmed the diagnosis of Sweet syndrome with pulmonary involvement. Our patient continues to require daily steroid therapy to prevent recurrence of symptoms. CONCLUSIONS: Overall, the aim of this case is to recognize the clinical and radiographic findings of pulmonary Sweet syndrome and to confirm the diagnosis based on the clinical criteria presented. Early initiation of corticosteroid therapy can result in favorable patient outcomes as discussed in this case. REFERENCE #1: Robbins CM, Mason SE, Hughey LC. Sweet Syndrome With Pulmonary Involvement in a Healthy Young Woman. Arch Dermatol. 2009;145(3):344–346. doi:10.1001/archdermatol.2008.610 REFERENCE #2: Fernandez-Bussy S, Labarca G, Cabello F, Cabello H, Folch E, Majid A. Sweet's syndrome with pulmonary involvement: Case report and literature review. Respir Med Case Rep. 2012;6:16-19. Published 2012 Oct 17. doi:10.1016/j.rmcr.2012.08.004 REFERENCE #3: Nofal A, Abdelmaksoud A, Amer H, Nofal E, Yosef A, Gharib K, Albalat W, Eldesouky F, Ebrahim HM, Abdelshafy AS, Fayed H. Sweet's syndrome: diagnostic criteria revisited. J Dtsch Dermatol Ges. 2017 Nov;15(11):1081-1088. doi: 10.1111/ddg.13350. Epub 2017 Oct 5. PMID: 28981179. DISCLOSURES: No relevant relationships by Huma Khan, source=Web Response

Atypical presentations of erythema nodosum leprosum: Diagnostic and therapeutic aspects.

Classic erythema nodosum leprosum (ENL) is characterized clinically by abrupt eruption of tender erythematous nodules, papules and plaques. Variable atypical patterns have been described, for example pustular, bullous, ulcerative, necrotic and Sweet's syndrome-like ENL. We aim to review previously reported cases of atypical ENL addressing the diagnostic and therapeutic aspects of these uncommon presentations. A search of medical literature for all cases of atypical ENL was conducted in the PubMed database till 2020. Data of patients with atypical ENL were collected and analyzed to describe the epidemiological, clinico-histological and therapeutic features. The major five clinically described presentations of atypical ENL include vesiculo-bullous lesions (46% of patients), ulcero-necrotic lesions (41%), erythema multiforme-like lesions (28%), Sweet's syndrome-like lesions (11%) and pustules (9%). The skin lesions were accompanied by fever and constitutional symptoms in all patients. Oral steroids and thalidomide were the main lines of therapy in most of the reported patients. Dermatologists and pathologists should keep in mind the clinical variability of ENL to avoid misdiagnosis and delayed management. Early recognition can help control disease progression and save the patients from further complications.

Erythema Nodosum: A Practical Approach and Diagnostic Algorithm.

Erythema nodosum is the most common form of panniculitis and is characterized by tender erythematous nodules mainly in the lower limbs on the pretibial area. The exact cause of erythema nodosum is unknown, although it appears to be a hypersensitivity response to a variety of antigenic stimuli. Although the etiology is mostly idiopathic, ruling out an underlying disease is imperative before diagnosing primary erythema nodosum. Erythema nodosum can be the first sign of a systemic disease that is triggered by a large group of processes, such as infections, inflammatory diseases, neoplasia, and/or drugs. The most common identifiable causes are streptococcal infections, primary tuberculosis, sarcoidosis, Behçet disease, inflammatory bowel disease, drugs, and pregnancy. We propose a diagnostic algorithm to optimize the initial work-up, hence initiating prompt and accurate management of the underlying disease. The algorithm includes an initial assessment of core symptoms, diagnostic work-up, differential diagnosis, and recommended therapies. Several treatment options for the erythema nodosum lesions have been previously reported; nevertheless, these options treat the symptoms, but not the triggering cause. Making an accurate diagnosis will allow the physician to treat the underlying cause and determine an optimal therapeutic strategy.

Abdominal pain and leg lesions: is there a connection?

A 63-year-old woman presented to the outpatient primary clinic with tender erythematous nodules and ulcers draining oily brown material on bilateral lower extremities ([figure 1A][1]). Her medical history was notable...

Pseudomonas folliculitis: a complication of the lockdown hot tub boom? Lessons from a patient.

An otherwise fit 58-year-old male presented with a sudden-onset rash on the buttocks and tenderness under the arms and left breast. His 25-year-old son had a similar rash on his torso and tenderness around the nipples bilaterally. Both patients were apyrexial. Over the next 24 hours redness developed at the site of tenderness under the arms and around the areolae. The family had bought a hot tub 3 weeks earlier and the father and son had longer immersion in the water compared with other family members, who were not affected. On examination there were tender erythematous nodules in the axillae (Figure 1) and around the left areola (Figure 2). There was follicular erythema with pustules over the buttocks (Figure 3). The son had similar changes in the axillae and around the areolae bilaterally with papules and pustules over the back (Figure 4). Figure 1. Erythematous nodules in the axilla. Figure 2. Erythema and induration of the peri-areola skin. Figure 3. Pustules and follicular papules with surrounding erythema over buttock. Figure 4. Papules and pustules over back. After 2 days pus started to discharge from the breast nodule of the son and a swab grew Pseudomonas aeruginosa . A diagnosis of Pseudomonas folliculitis with …

Cutaneous Plasmacytoma: A Case Report

Introduction: Multiple myeloma is a rare haematological malignancy of plasma cells commonly presenting in the fifth and sixth decade. Uncommonly, multiple myeloma can present with cutaneous manifestations. Usually these lesions occur as a result of an infiltrative extension of osteolytic bone lesions. Case Presentation: A 72-year-old gentleman with a large malodorous fungating lesion on his right thigh. A skin biopsy demonstrated that the lesions are deposits of known kappa light chain plasma cell myeloma. Conclusions: Cutaneous plasmacytoma typically presents as erythematous or violaceous hard and tender nodules or plaques. Treatment involves chemotherapy, steroids, local radiotherapy and surgery. The discovery of cutaneous metastatic plasmacytomas can be the first sign of progression of the disease or signal a deteriorating clinical course in multiple myeloma therefore prompt investigation is essential.