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erythema induratum Oct 4 ZAhmad

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					A Case of Erythema Induratum

Case Presentation
32 year old female, originally from India  January: painless left neck nodules  April: developed painful red nodules on lower legs.  Accompanied by bilateral knee pain and ankle swelling.
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Erythema Induratum

Case Presentation
No respiratory symptoms, fever, chills, sweats.  No genitourinary / abdominal / neurologic complaints.  Deliberate 35 lbs. weight loss in two years.
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Case Presentation
No preceding infection history / infected contacts / specific TB exposure.  Traveled to India 2002  HIV - when pregnant two years ago.  Received BCG in past  Lives with husband and 2.5 year old son
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Skin Biopsy

Biopsy Results (June)
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Lobular panniculitis with areas of fat necrosis, histiocyte infiltrate, and granulomatous appearance throughout the fat lobules. Some vascular involvement with some vessels appearing completely necrotic. Scattering of lymphocytes and a few plasma cells. Compatible with lobular pnniculitis with vasculitis and therefore compatible with erythema induratum. AFB negative.

Case Presentation
Started on Celebrex, with improvement of skin, knee pain, ankle swelling.  August 20: Assessed by ID.  PPD positive with blistering, erythema and induration greater than 3 cm.  Started on INH, referred for knee pain.
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PPD Reaction

Case Presentation
BP 120/70 H 155.5 cm W 102.5 kg  5-6 mobile, soft, non-tender nodes in left anterior chain and supraclavicular area. No other adenopathy.  Normal respiratory, cardiac exam. Dull over Castell’s point.
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Case Presentation
2 cm red patch with central necrosis on right inner forearm  Several bluish patches on lower legs, apparently healing. Some with darker centres.  Tender over both anserine bursae, slight patellar crepitus.
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Case Presentations
Normal CXR  Hgb 127; MCV 70.9  WBC 8.23; normal differential; Plt 308  ESR 26  ALT 47; AST 58; ALP 116  Hep B, C, VDRL negative  U/A normal
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Extrapulmonary TB
Can occur at initial infection or years later.  Risk increased with immunocompromise, age, comorbidities.  Increasingly seen due to HIV.  Occurs in 20% of non-HIV patients with TB  Occurs in 53-62% of TB patients with HIV
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Order of Frequency of Sites of Extrapulmonary TB
Lymph nodes  Pleura  GU tract  Skeleton (usually axial)  Meninges  Peritoneum  All organ systems can be involved
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Tuberculous Lymphadenitis
Usually unilateral painless swelling of cervical or supraclavicular nodes.  Nodes usually discrete with normal overlying skin.  If untreated, become matted, skin becomes inflamed and nodes rupture.  May cause sinus tract formation, scarring.
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Tuberculous Lymphadenitis

Tuberculous Lymphadenitis

Tuberculous Lymphadenitis
Systemic symptoms are unusual in isolated T.L. if HIV-negative.  Formerly thought of as a childhood condition.  Peak onset now 20-40 years  Females>Males  More in Asian Pacific islanders
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Tuberculous Lymphadenitis
Can also affect axillary, mesenteric, mediastinal, intramammary nodes.  Mediastinal involvement can cause dysphagia, vocal cord paralysis, PA occlusion, bronchus constriction.  Abdominal involvement causes jaundice, portal hypertension, portal vein thrombosis, renovascular HTN.
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Tuberculous Lymphadenitis
Diagnosed by FNA and Ziehl-Neelsen staining. Yield improved by PCR.  May require excisional biopsy for histology, culture, PCR.  Treated in same manner as pulmonary TB.
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Erythema Induratum or Nodular Vasculitis
TB isolated by PCR in 77% of cases.  Usually middle-aged women.  More common in obesity, venous insufficiency.  Red, tender, subcutaneous nodules on posterior lower legs, ankles.  May ulcerate and scar.
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Erythema Induratum or Nodular Vasculitis
Lobular panniculitis with necrosis of adipocytes.  Histiocytes infiltrate and ingest lipid, becoming foamy.  Granulomatous appearance.  Vasculitis of veins? Arteries? Both?  In context of positive PPD or PCR, should be treated as TB.
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posted:4/17/2008
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