Erythema Nodosum in a 42-Year-Old Man

July 1, 2004

A mildly painful, nonpruritic rash on the forearms and legs prompted a 42-year-old man to go to the emergency department. The patient noted the rashwhen he awoke that morning. He had had joint pain and fever for the past7 days and generalized malaise with chills that began about 3 days earlier.He had no significant medical history.

A mildly painful, nonpruritic rash on the forearms and legs prompted a 42-year-old man to go to theemergency department (ED). The patient noted the rashwhen he awoke that morning. He hadhad joint pain and fever for the past7 days and generalized malaise withchills that began about 3 days earlier.He had no significant medical history.In the ED, the patient was afebrile;his blood pressure was 130/85mm Hg; respiration rate, 16 breathsper minute; and heart rate, 96 beatsper minute. He complained of chillsbut denied headache, visual changes,nausea, vomiting, constipation, diarrhea,abdominal pain, and recentinsect bites. He had no history of recenttravel or new medications.The day before his ED visit, thepatient had been seen by his primarycare physician, who ordered laboratorytests. The patient's erythrocytesedimentation rate was slightly elevated;antinuclear antibody (ANA) anduric acid levels were normal. Testsfor Lyme disease, Epstein-Barr virusinfection, and active Mycoplasma infectionwere negative.When Robert Levine, DO, ofLong Beach, NY, examined the patientat the hospital, he noted large, painful, subcutaneous nodules withoverlying erythema on the distalupper and lower extremities andankle and wrist edema. He admittedthe patient and sought cardiology,infectious disease, and rheumatologyconsultations.The cardiologist initially suspectedinfectious endocarditis; however,a 2-dimensional echocardiogramshowed no obvious valvular vegetations.A hepatitis profile and bloodcultures were negative. Levels ofANA, rheumatoid factor, C3, and C4were normal. Angiotensin-convertingenzyme levels were elevated. A chestradiograph revealed bilateral hilarlymphadenopathy that pointed to a diagnosisof sarcoidosis.Erythema nodosum is an acuteinflammatory/immunologic reactionpattern of the panniculus. The mostcommon causes are infections (eg,tuberculosis, histoplasmosis, β-hemolyticstreptococcus infection, coccidioidomycosis,and leprosy); reactionsto pharmacologic agents (eg, sulfonamidesand oral contraceptives); sarcoidosis;ulcerative colitis; and Behetsyndrome. The cause is idiopathic inabout 40% of cases.1 Treatment ismainly symptomatic. Anti-inflammatoryagents such as NSAIDs and salicylateshave shown some benefit.Systemic corticosteroids are helpful,but only when the cause is knownand infectious agents are ruled out.1This patient was treated withbed rest and ibuprofen as needed forbreakthrough pain and chills. Hewas discharged with instructions toincrease his fluid intake and to schedulea follow-up visit with his primarycare physician, who would coordinatelong-term treatment of sarcoidosis.Prednisone was started at 20 mg/dand then tapered (5 mg every 2weeks) over 8 weeks. The rash andsymptoms resolved within 6 to 8weeks.