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. Erythema Induratum Case Presentation No respiratory symptoms, fever, chills, sweats. No genitourinary / abdominal / neurologic complaints. Deliberate 35 lbs. weight loss in two years. 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 Skin Biopsy Biopsy Results (June) 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. 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. 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. 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 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 Order of Frequency of Sites of Extrapulmonary TB Lymph nodes Pleura GU tract Skeleton (usually axial) Meninges Peritoneum All organ systems can be involved 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. 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 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. 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. 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. 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.