FANS (mnemonic): for eythema nodosum

1. fever
2. arthralgia
3. erythema Nodosum
4. Systemic upset

See video

 

Description:

• multiple, violaceous nodules of variable sizes on the shin and extensor surface of lower legs

 

Characteristics of the lesion?

• painful
• non ulcerated,
• healing witout scarring
• spontaneous resolution leaving bruise like mark
• presence over extensor surface of legs

Six causes of EN

1. Infections:   

• • Bacteria: streptococci, mycobacteria, Mycoplasma, Rickettsia, Chlamydia  
  • Viruses: hepatitis B and infectious mononucleosis 
  • Fungi 

      2. Drugs: Sulphonamides, sulphonylureas, oral contraceptives 

     3. Systemic disease:  Sarcoidosis, IBD, malignancy 

     4. Other  Pregnancy

 

Treatment of EN in general:

• Bed rest, leg elevation
• Oral NSAID
• Systemic glucocorticoids →  must be avoided when there is a possibility of infection.
• For resistant disease:
  • dapsone
  • potassium iodide
  • hydroxychloroquine
• Treatment of underlyng cause

 

Q. What S/S, will you look for?

symptoms	signs
cough, haemoptysis, SOB red eye, fever joint pain abdominal pain limb weakness,	Lupus parnio, Parotid swelling CN palsy, mainly 7th CN Lymphadenopathy, Splenomegaly Arthritis Papilloedema

 

Q. 6 emergency?

1. Hypercalcemia
2. tension pneumothorax, respiratory failure
3. cardiac arrhythmia, conduction block
4. convulsion
5. uveitis

 

SAQ/LQ: A 20-year-old female presented with fever for 12 days with painful nodules at leg for 5 days. On examination there are multiple erythema nodosum at both legs.

a) What information you may gather from history?

b) what signs would you search to reach a diagnosis? 

c) how will you investigate her?

 

Answer 

 

Key points

• Age: 12 years
• Gender: Female

 

Presenting complaints

• fever for 12 days
• painful nodule  over the lags

 

O/E:

• Multiple Erythema nodosum 

 

From the scenario, etiology of the lesion are 

• Sarcoidosis
• Tuberculosis
• IBD
• pregnancy
• Histoplasmosis
• Drugs – OCP, sulphonamide

 

Clinical Evaluation 

 

History/symptoms	Signs	Possible diagnosis
low grade fever weight loss night sweats cough	weight loss anemia lymphadenopathy hepatosplenomegaly F/O pleural effusion, consolidation	Tuberculosis
fever, arthralgia dry cough exertional dyspnea red eye polyuria, polydipsia	lupus pernio splenomegaly lymphadenopathy anterior uveitis CN palsy enlarged lacrimal and parotid glands	sarcoidosis
passage of blood mixed stool mucous stool weight loss abdominal pain	chacecxia anemia oral ulcer uveitis	IBD
fever weight loss	lymphadenopathy hepatosplenomegaly	histoplasmosis
H/O amenorrhea abdominal fullness anorexia, nausea,vomiting	gravid uterus fetal heart sound	pregnancy
Drug history		OCP

 

Investigation:

Investigation will be guided by clinical history and examination findings.

 

Investigation	Finding	Diagnosis
FBC	anemia lymphopenia high ESR	TB, IBD, histoplasmosis sarcoidosis TB, IBD, sarcoidosis
MT	elevated	TB
S calcium, S.ACE	elevated	sarcoidosis
CXR	Bilateral Hilar LN Patchy opacities	sarcoidosis, TB TB
Skin biopsy	non caseating granuloma caseating granuloma	sarcoidosis TB
sputum -AFB, Gene Xpert sputum for fungal stain	Positive for AFB positive	TB histoplasmosis
IGRA	Positive	TB
HRCT	reticulonodular shadow	TB, sarcoidosis
Bronchoscopy with BAL	cobblestone appearance  CD4:CD8 high	sarcoidosis
Colonoscopy, Ileocolonoscopy	ulcer, fissure	IBD
Pregnancy test	positive	pregnancy

 

Treatment:

• General treatment:

• NSAIDs etc 

• specific treatment : according to underlying cause