1415 Al-Mashaleh, et al: Bazin’s disease Images in Rheumatology Clinical Images: Bazin’s Disease (Erythema Induratum) MANALAL-MASHALEH, MD, JBM, Visiting Fellow, Rheumatology Department; DON PACKHAM, MBBS, FRACP, Staff Specialist, Infectious Disease Department, Westmead Hospital; NICHOLAS MANOLIOS, MBBS(Hons), MD, PhD, FRACP, FRCPA, Director of Rheumatology, Associate Professor, University of Sydney, Rheumatology Department, Westmead Hospital, Sydney, Australia. Address reprint requests to Dr. Manolios. E-mail: [email protected] Our case highlights the similarity between erythema nodosum (EN) and erythema induratum (EI) and illustrates the impor- tance of Mantoux testing in investigations of patients with vasculitis, particularly those from tuberculous-endemic areas; as well, it points to the need for biopsy if apparent EN has atypical or prolonged course or is complicated by ulceration, and the resolution of EI with anti-TB treatment alone. A 16-year-old Indonesian girl with a 2 year history of Sjögren’s syndrome (SSA/SSB-positive) and hepatitis C and taking no medications presented with a 2 week history of painful erythematous nodules over the anterior aspect of her lower limbs (Figure 1A) and forearms. The clinical picture was that of EN. Investigations including a chest radiography were normal, apart from positive Mantoux with 20 mm induration. Biopsy of a nod- ule showed granulomatous inflammation extending from the dermis into the panniculus, with no evidence of nerve or vessel involvement (Figure 1B). Ziehl-Neelsen stains for Myco- bacterium tuberculosis were negative, as was DNA polymerase chain reaction (PCR). A diagnosis of EI was made and the patient commenced anti-TB treatment. Followup several weeks later showed resolution of the skin lesions. Bazin’s disease (EI) is an under-recognized chronic recur- rent condition characterized by painless, deep-seated, subcuta- neous induration, which gradually extends to the skin surface, forming bluish-red nodules or plaques, which then often ulcer- ate 1,2 . The morphologic, molecular, and clinical data suggest that EI represents a hypersensitivity reaction to tubercle bacil- lus 3 . As described, it is not unusual to have negative cultures and fail to detect M. tuberculosis by PCR amplification 2,4 . REFERENCES 1. Bayer-Garner IB, Cox MD, Scott MA, Smoller BR. Mycobacteria other than Mycobacterium tuberculosis are not present in erythema induratum/nodular vasculitis: a case series and literature review of the clinical and histologic findings. J Cutan Pathol 2005;32:220-6. 2. Jacinto SS, Nograles KB. Erythema induratum of Bazin: role of polymerase chain reaction in diagnosis. Int J Dermatol 2003;42:380-1. 3. Schneider JW, Jordaan HF. The histopathologic spectrum of erythema induratum of Bazin. Am J Dermatopathol 1997;19:323-33. 4. Vieites B, Suarez J, Penaranda M, et al. Recovery of Mycobacterium tuberculosis DNA in biopsies of erythema induratum — results in a series of patients using an improved polymerase chain reaction technique. Br J Dermatol 2005;152:1360-98. Figure 1. A. Vasculitis lesions were red, tender, raised, and predominantly over the anterior aspect of the leg. B. Histopathological findings from a sub- cutaneous nodule biopsy on the lower leg, showing florid granulomatous inflammation. No organisms were seen. Special stains for mycobacterium and fungi were negative. A B Personal non-commercial use only. The Journal of Rheumatology Copyright © 2006. All rights reserved. www.jrheum.org Downloaded on July 28, 2022 from
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1415Al-Mashaleh, et al: Bazin’s disease
Images in Rheumatology
Clinical Images: Bazin’s Disease (Erythema Induratum)MANAL AL-MASHALEH, MD, JBM, Visiting Fellow, Rheumatology Department; DON PACKHAM, MBBS, FRACP, Staff Specialist, InfectiousDisease Department, Westmead Hospital; NICHOLAS MANOLIOS, MBBS(Hons), MD, PhD, FRACP, FRCPA, Director of Rheumatology, AssociateProfessor, University of Sydney, Rheumatology Department, Westmead Hospital, Sydney, Australia. Address reprint requests to Dr. Manolios. E-mail:[email protected]
Our case highlights the similarity between erythema nodosum(EN) and erythema induratum (EI) and illustrates the impor-tance of Mantoux testing in investigations of patients withvasculitis, particularly those from tuberculous-endemic areas;as well, it points to the need for biopsy if apparent EN hasatypical or prolonged course or is complicated by ulceration,and the resolution of EI with anti-TB treatment alone.
A 16-year-old Indonesian girl with a 2 year history ofSjögren’s syndrome (SSA/SSB-positive) and hepatitis C andtaking no medications presented with a 2 week history of painfulerythematous nodules over the anterior aspect of her lower limbs(Figure 1A) and forearms. The clinical picture was that of EN.Investigations including a chest radiography were normal, apartfrom positive Mantoux with 20 mm induration. Biopsy of a nod-ule showed granulomatous inflammation extending from thedermis into the panniculus, with no evidence of nerve or vesselinvolvement (Figure 1B). Ziehl-Neelsen stains for Myco-bacterium tuberculosis were negative, as was DNA polymerasechain reaction (PCR). A diagnosis of EI was made and thepatient commenced anti-TB treatment. Followup several weekslater showed resolution of the skin lesions.
Bazin’s disease (EI) is an under-recognized chronic recur-rent condition characterized by painless, deep-seated, subcuta-neous induration, which gradually extends to the skin surface,forming bluish-red nodules or plaques, which then often ulcer-ate1,2. The morphologic, molecular, and clinical data suggestthat EI represents a hypersensitivity reaction to tubercle bacil-lus3. As described, it is not unusual to have negative culturesand fail to detect M. tuberculosis by PCR amplification2,4.
REFERENCES1. Bayer-Garner IB, Cox MD, Scott MA, Smoller BR. Mycobacteria
other than Mycobacterium tuberculosis are not present in erythemainduratum/nodular vasculitis: a case series and literature review ofthe clinical and histologic findings. J Cutan Pathol 2005;32:220-6.
2. Jacinto SS, Nograles KB. Erythema induratum of Bazin: role ofpolymerase chain reaction in diagnosis. Int J Dermatol2003;42:380-1.
3. Schneider JW, Jordaan HF. The histopathologic spectrum oferythema induratum of Bazin. Am J Dermatopathol 1997;19:323-33.
4. Vieites B, Suarez J, Penaranda M, et al. Recovery ofMycobacterium tuberculosis DNA in biopsies of erythemainduratum — results in a series of patients using an improvedpolymerase chain reaction technique. Br J Dermatol2005;152:1360-98.
Figure 1. A. Vasculitis lesions were red, tender, raised, and predominantlyover the anterior aspect of the leg. B. Histopathological findings from a sub-cutaneous nodule biopsy on the lower leg, showing florid granulomatousinflammation. No organisms were seen. Special stains for mycobacteriumand fungi were negative.A
B
Personal non-commercial use only. The Journal of Rheumatology Copyright © 2006. All rights reserved.
www.jrheum.orgDownloaded on July 28, 2022 from
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