Diagnosis: Erythema induratum (nodular vasculitis)
A 45-year-old female presents with painful ulcerating nodules on the posterior calves, persisting for several weeks. Examination reveals tender, erythematous nodules with ulceration, prompting further investigation into underlying causes of vasculitis.
A 45-year-old female presents with painful ulcerating nodules on the posterior calves, which have been present for approximately six weeks. The patient reports increasing discomfort and difficulty walking due to the lesions. On examination, there are multiple tender, erythematous nodules with central ulceration located predominantly on the posterior aspect of both calves. The surrounding skin appears edematous and erythematous, with some nodules exhibiting purulent drainage.Location: Posterior calves, bilateral.Lesion characteristics: Painful, ulcerating, erythematous nodules.Associated symptoms: Tenderness, discomfort with ambulation.Duration: Ongoing for six weeks.Systemic symptoms: No fever or systemic illness reported.
The patient reports that the nodules began insidiously, with no known precipitating factors. She has a history of hypertension and hyperlipidemia, managed with medication. There is no known history of autoimmune disease, and her family history is unremarkable for similar conditions. She denies recent travel or exposure to infections. Prior over-the-counter treatments, including topical antibiotics, have not improved the lesions.Onset: Insidious over six weeks.Previous treatments: Topical antibiotics without improvement.Medical history: Hypertension and hyperlipidemia.Family history: No autoimmune diseases.Social history: Non-smoker, no recent travel or infections.
Acute / First-Line ManagementInitiate prednisone at 1 mg/kg/day for 1-2 weeks, tapering based on clinical response.Consider nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management.If no improvement, consider dapsone 50-100 mg daily as a second-line option.Workup and Diagnostic ConfirmationPerform a skin biopsy for histopathological evaluation to rule out other causes of panniculitis.Order laboratory tests including complete blood count, inflammatory markers (ESR, CRP), and autoimmune panel.Consider cultures of any purulent drainage to rule out infectious etiologies.Long-Term ManagementMonitor patient regularly for lesion resolution and manage any underlying conditions.Consider long-term immunosuppressive therapy if recurrent episodes occur, such as azathioprine or methotrexate.Educate the patient on avoiding known triggers, including infections and trauma.
Granuloma annulare: Typically presents as annular plaques rather than nodules; lacks ulceration.Leukocytoclastic vasculitis: Often associated with systemic symptoms and palpable purpura; biopsy shows neutrophilic infiltrate.Deep fungal infections: Can present with nodular lesions; history of immunosuppression or travel may aid diagnosis.Necrobiosis lipoidica: More common in diabetics; lesions are usually not painful and have a characteristic yellow-brown appearance.Subcutaneous fat necrosis: Typically seen in newborns or after trauma; may involve the lower extremities.Behçet's disease: Associated with recurrent oral and genital ulcers; systemic symptoms may be present.Drug-induced panniculitis: Consider medications taken by the patient; history of new drug exposure may guide diagnosis.Cutaneous sarcoidosis: Can present with nodules and ulceration; may have systemic involvement and requires biopsy for confirmation.
High-Yield PearlsDiagnosis: Erythema induratum is a form of nodular vasculitis often associated with underlying tuberculosis, necessitating thorough workup.Biopsy: Histological examination is crucial for accurate diagnosis and differentiation from other panniculitides.Systemic treatment: Corticosteroids remain the cornerstone of therapy for acute lesions, with careful tapering to avoid rebound.Trigger avoidance: Educating patients on avoiding known triggers, including infections, can help prevent recurrence.Long-term management: May require immunosuppressive agents for recurrent cases, emphasizing the need for ongoing monitoring.Timely recognition and management of nodular vasculitis can prevent complications and improve patient outcomes.
Tags: erythema induratum, nodular vasculitis, tuberculid