Erythema nodosum L52.0

Acute, usually infection-related (frequently streptococcal infections), self-limiting panniculitis associated with general symptoms such as fever and arthralgias as well as subcutaneous, painful nodules (predominantly) on the extensor sides of the lower legs.

Panethnic. Most common septal panniculitis. Prevalence in Central Europe: 100-200/100.000 inhabitants/year. Incidence in Central Europe: 2-8/100,000 inhabitants/year.

In a larger proportion of cases (30-50%), exact attribution to a triggering cause is not possible. In addition to these "idiopathic" cases, infectious and/or drug-allergic causes or combinations thereof can be detected. The spectrum of infections is very different in the various regions of the world. World regions very different.

• The underlying immune mechanisms are not clearly defined; the formation of so-called Miescher's radial nodules in the fatty tissue septa suggests a panniculitis primarily occurring in the septal connective tissue.
• Erythema nodosum occurs in:
  • Rheumatic fever
  • Tuberculosis
  • Sarcoidosis
  • Enteritis regionalis
  • Sweet syndrome
  • Pregnancy
  • Contraceptives (progestogen component?)
  • Takayasu arteritis (in approx. 10% of patients with TA)
  • Behcet's disease (in approx. 80% of cases, recurrent)
• Further "infectious-allergic" with:
  • Streptococcus infections (frequent cause!)
  • Hepatitis B virus infections
  • Cat scratch disease
  • Salmonella enteritis
  • Lymphogranuloma inguinale
  • Coccidioidomycosis
  • Inguinal lymphogranuloma
  • Ornithosis
  • Yersini infections
  • Infectious mononucleosis
  • Toxoplasmosis
  • deep mycoses.

Mostly occurring in adults between the ages of 20-40. Also occurring in children and adolescents. Usually symmetrical, described unilaterally in rare cases.

f:m=3-6:1

Seasonally clustered in spring and autumn.

Beginning with general symptoms such as fever, fatigue, tiredness, rheumatoid pain as well as symmetrically and bilaterally arranged, light or bright red, blurred, 2.0-10.0 cm in size, pressure pain, sometimes extremely pressure pain (so that even light touching is felt as unpleasant), doughy, slightly raised, reddish-livid lumps or plaques with a smooth, taut surface. The skin changes can confluent to larger (up to 5-15 cm) areas. The nodules never ulcerate. The single foci heal within 3-6 weeks with a change of colour (from reddish-brown to reddish-brown to brown-yellow and a slight grey-yellow) without scarring. In the eruption phase fresh spurts can occur.

Rare is a migratory centrifugal expansion of the foci, an activity state also known as subacute migratory panniculitis (panniculitis subacuta nodularis migrans) or erythema nodosum migrans.

Initial: infiltration by neutrophil granulocytes in the adipose tissue septum, formation of Miescher's radial nodules; edema, macrophages, foam cells.

Full-stage: granulomatous reaction of the adipose tissue; non-specific concomitant reaction in the reticular dermis; adipose tissue septums are fibrotically transformed.

Erythema induratum: chronic persistent, infectious allergic lobular panniculitis combined with vasculitis of the small vessels of the fat lobules. The dorsal parts of the lower leg are affected. The delimitation as an independent entity is still controversial!

Polyarteritis nodosa cutanea: Painful nodules and plaques: often onset with recurrent vasculitic plaques or nodules (iceberg phenomenon), 1.0 - 5.0 cm in size, rough, usually very pressure-dolent, also spontaneously painful, reddish to livid in colour. Not infrequently painful ulcers (60%).

Syphilitic gummata: Rare; serologic evidence of syphilis.

Nodular medicinal erythema: Exanthematous seeding of nodular erythema. Anamnestic relationship to drug administration.

Pernio:Acral localization of inflammation. Anamnestically clear dependence of the symptomatology on cold influences.

Cold panniculitis: Localized inflammation of the subcutaneous adipose tissue, in the wake of external influences such as cold or wetness. Typically, 2 to 3 days (rarely delayed to 10-14 days) after local hypothermia, deeply cutaneous, succulent, painful nodules appear in the adipose tissue. Classically in riders on the extensor sides of the thighs.

Pancreatic panniculitis: in lipase-producing eccrine pancreatic carcinoma or also in acute or chronic (often alcohol-induced) pancreatitis.

Nodular erythema in Behcet's disease: probably identical with classic erythema nodosum.

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