Painful red lesions on the shins. Trauma? Tumor? Inflammation? The diagnosis is in the detailed differential you'll follow in this slide show.
On a busy clinic day, 6-year-old Polly limped into the outpatient clinic and was admitted because of the painful lumps on her lower legs. You are asked to evaluate her. Her history reveals: a sore throat 4-5 weeks ago; red, very tender nodules over her shins that have been present for 2 weeks.
Past medical history: non-contributory. No travel. No recent immunizations. Other than the previous sore throat, no illnesses.No fever, weight loss, bruising.
Review of systems. no trauma. not taking any medications. Physical examination is significant only for 1- to 4-cm oval, reddish-brown, easily palpable firm nodules over the surface of the anterior tibia. The overlying skin is tight and starting to peel.
Note the nodular lesions on the surface of the anterior tibia and that the overlying skin is peeling.
Differential diagnosis: First, lets eliminate a few categoriesâ¦based on the history and physical examination, it is not traumatic, or an obvious infection. Could it be a tumor? Could it be an inflammatory condition? Benign and malignant tumors can cause lumps including: Fibroma, lipoma, lymphoma, osteosarcoma, sarcoma. Do any of these seem to fit?
Differential diagnosis...Could it be an inflammatory condition? Inflammatory conditions to consider include: Erythema nodosum; gout; pseudogout; osteoarthritis; psoriatic arthritis; rheumatoid arthritis; systemic lupus erythematosus; some other form of vasculitis.
Answer: Erythema nodosum. A delayed cell-mediated hypersensitivity. Respiratory etiology most common cause in children. Recent streptococcal infections most common type in children.Remember, there is a 10% recurrence rate. Red, tender nodular lesions most commonly on the pretibial surface of the legs. Not suppurative.
Erythema nodosum. Histopathologic features: lymphocytic perivascular infiltrate in dermis. lymphocytes & neutrophils in the fibrous septa; in subcutaneous fat. If you make the clinical diagnosis, however, histology is not likely to be required
Erythema nodosum: etiology. Infections: Infections: group A B-Strep, infectious mononucleosisinfluenzae, herpes, tuberculosis, histoplasmosis, coccidiomycosis, cat scratch disease, leprosy. psittacosis, lymphogranuloma venereum, measles, ascariasis, leishmaniasis. Also ulcerative colitis, pancreatitis.
Erythema nodosum etiology, continued. Malignancy: leukemia, hodgkin, non-hodgkin. Collagen-vascular: systemic lupus erythematosus, polyarteritis nodosa, sarcoidosis. Drug-induced: Sulfonamides, oral contraceptives, salicylates, thiazides, dilantin, iodides, bromides, phenacetin.
Erythema nodosum etiology: Biologicals: bacille Calmette-Guerin vaccine, diphtheria antitoxin and toxoid, pure pollen extracts, vaccines.
There are times when erythema nodosum is somewhat atypical...It is important, then, to remember that erythema nodosum falls into the category of panniculitis...
Represents infiltration of subcutaneous tissues by inflammatory and / or neoplastic cells. Apparent as deep induration or swelling of the skin. Associated signs include erythema, ulceration, drainage, warmth, and pain or tenderness.
Erythema nodusum is a septal panniculitis. Predominance of inflammation involves the connective tissue septa between the fat lobules. Lobular panniculitis: inflammation is of the fat lobules themselves.
Septal panniculitis: erythema nodosum, subacute nodular migratory panniculitis (scleroderma)Lobular and mixed panniculitis: Vasculitis and connective tissue, lupus, erythema induratum, other connective tissue. Lobular and mixed panniculitis: Metabolic: altered melting points of fat in the newborn, seen in subcutaneous fat necrosis and sclerema, pancreatic, alpha-1-antitrypsin deficiency. Traumatic. Infectious. Malignancy. Lipodystrophy.
Polly is 6-years-old and is admitted to hospital for painful red nodules on her shins that have been present for 2 weeks. She has no fever, has not been immunized recently, and has no travel history. She had a sore throat a few weeks ago but that has resolved. What's causing the painful lesions on her legs?It's another in our series of thought-provoking cases from Dr Jonathan Schneider. The well- considered differential diagnosis is key to resolving his cases and he walks you deliberately through the details. Trauma? Tumor? Inflammatory condition? Follow the slides above and find out.Â Â Â
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