ERYTHEMA NODOSUM

Synonyms.—Dermatitis contusiformis; Fr., Erythème noueux; Ger., Erythema
nodosum.

Definition.—Erythema nodosum is an inflammatory affection
of an acute type, characterized by the formation of variously sized,
roundish, more or less elevated, erythematous nodes or swellings, at­
tended with a variable degree of systemic disturbance.¹

Symptoms.—Erythema nodosum is usually ushered in with febrile
disturbance, gastric uneasiness, malaise, and, not infrequently, with
rheumatic swellings and pains about the joints. These constitutional
symptoms may be of a mild and scarcely noticeable character, or they
may be severe. The cutaneous eruption makes its appearance sud­
denly, either concomitantly with the foregoing systemic symptoms,
or some hours or a day after their onset. The lesions are seen for the
most part upon the tibial surfaces, and may often be limited to these
regions; not infrequently, however, other regions may be involved, more
especially the arms and forearms. The lesions may also occur, though
only exceptionally, on the mucous surfaces of the mouth and throat
(Duhring, Pospelow, Kaposi, Rasumow). They are rarely present in

¹ Some important literature: S. Mackenzie (analysis of 108 cases and relation to
rheumatism), London Clin. Soc. Trans., 1886, vol. xix, p. 215; Schulthess (analytic
study), Correspondenzbl. f. Schweiz. Aerzte, 1895, No. 3; Numa Bés (association with
diseases of genito­urinary organs), These de Paris, 1872; Amiaud, V Erythemenoueux;
ses Complications viscérates, 1879, Paris; Uffelmann (associated with tuberculosis),
Archiv, 1874, p. 174; 1877, p. 230; and also Oehme, ibid., 1878, p. 324; Knipe (cases
simultaneously in same family), Brit. Med. Jour., 1882, vol. ii, p. 974, and also Demme,
Fortschritte der Med., 1888, No. 7; Duhring, loc. cit.; Harrison, Brit. Jour. Derm., 1900,
p. 250 (analytic remarks concerning 80 cases); E. Hoffmann (etiology and patho-
genesis), Deutsch. med. Wochenschr., 1904, vol. xxx, p. 1877.

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INFLAMMATIONS

great number, the eruption usually being made up of from several to
twenty or thirty nodes. They begin, as a rule, as deep-seated nodules,
rapidly growing larger and becoming elevated. They are from a cherry
to a hen-egg or even larger in size, are rounded or oval, tender and pain­
ful, and have a glistening and tense look, and are of a bright red, erysipela-
tous color that merges gradually into the sound skin. They are not
sharply circumscribed. Later the color grows of a darker hue and be­
comes purplish or violaceous, and, in disappearing, gradually undergoes
the various color changes of a bruise—bluish, bluish-yellow, and greenish,
muddy yellow. In occasional instances they are distinctly hemorrhagic
When first appearing they are quite firm, but gradually, after reaching
their full development, in the course of several days or one or two weeks,
they soften, become semifluctuating, and appear as if about to break
down, but suppurative or destructive changes, however, never occur,
absorption invariably taking place; there are several recorded exceptions
(Demme, Uffelmann, Hardy, Purdon, Haisolt), but which must have
been due, I believe, to some accidental factor or complication. There
may be, in some cases, associated lesions of erythema multiforme. The
subjective symptoms are rarely severe, although occasionally trouble­
some, consisting of tenderness, pain, and sometimes throbbings.

The course of the disease varies somewhat in different cases. As
a rule, the nodes do not all come out at one time, but there is, at first,
an appearance of three or four, and these are soon followed by others.
After some days or a few weeks new lesions cease to appear, and the
process gradually declines, the oldest fading away first, going through
the various color changes referred to. In the course of several weeks
or a few months all traces of the eruption will have entirely disappeared.

The constitutional symptoms usually abate in average cases after
the first several days. In extreme instances, however, there may be
continuous febrile action, similar to that observed in fevers, and ex­
ceptionally it seems to partake of the nature of a prolonged febrile
disease (Hutchmson, Bäumler). Cases of this disease have also been
reported from time to time in which there were signs pointing to visceral
involvement and even cerebral invasion, these graver symptoms some­
times markedly ameliorating or abating upon the appearance of the
eruption upon the skin. Endocarditis is occasionally noted; in Macken-
zie's cases (108), in 5 cases heart murmurs developed during the attack,
apparently due to this disease.

Etiology.—The disease is met with most usually in those under
the age of thirty. Mackenzie's statistics of 108 cases give: 14 cases
under the age of ten; 69 cases between the ages of ten and thirty; 15
between thirty and forty; and 10 in those over forty years of age. Females
are much more frequently affected than males—by one analysis (Mac­
kenzie), 5 to 1; by others (Schulthess and Harrison), 3 to 1. It is more
common in cold and damp seasons (Duhring). While it may occur in
those seemingly in good health, its most frequent subjects are among the
weak and anemic. The frequently associated rheumatic symptoms ob­
served would indicate some connection with this disease (Garrod, Mac­
kenzie, Begbie, Durian, Legrand, Besnier, Boeck, and others), but whether

ERYTHEMA NODOSUM                                 163

causative or simply as a manifestation of the same underlying factor is
not known. The urine discloses practically nothing, although Cursch-
mann states that in 25 cases he met with hemorrhagic nephritis 5 times.
Among other factors which have been variously thought to be of influence
may be mentioned malaria (Boicesco, Moncorvo), digestive disorders,
auto­intoxication, defective sanitation (Moore), drugs, etc It is not a
common disease.

Pathology.—The nature of the disease is not clear. The febrile
action and the occasional visceral involvement or complications would,
I believe, point rather strongly to a specific infection, and this is the
present trend of opinion.¹ The simultaneous occurrence of the disease
in two or more members of the same family (Knipe, Demme), or one
after another (Nash, Little), would lend support to this belief, but such
cases are extremely rare. Doubtless in the grave cases reported the dis­
ease may be due to septic infection. The reported cases (Amiaud,
Uffelmann, Oehme, Lailler, Goldschneider, Talamon, Buisine) of asso­
ciated or subsequent tuberculosis, usually grave in character, would
indicate simply the presence of a predisposing factor, and must be con­
sidered rare or purely accidental.² Its occurrence in the course of
syphilis (Despres, Leloir, Mauriac, Testut, Jackson) seems too rare to
be viewed more than as a coincidence.³

Its relation to erythema multiforme is certainly a close one, and
many (E. Wilson, Lewin, Auspitz, Polotebnoff, Kaposi, Besnier, Brocq,
Boeck, Crocker, Hyde, and others) believe it to be a manifestation of
this disease, and cases are occasionally reported, among which recently
those by Gibb,⁴ Glück,⁵ and Schein,⁶ in which lesions of both erythema
multiforme and erythema nodosum are alleged to have been present.
In a few cases under my own observation the eruption seemed of mixed
character. Nevertheless, the distinct individuality of erythema nodo-
sum is strenuously maintained by many leading clinicians and pathol-
ogists (Hebra, Neumann, Düring, Vidal, Leloir, Duhring, Schulthess,
Veiel, Unna, Jadassohn, Jarisch, and others). Düring, in 105 cases of
erythema multiforme, never saw an erythema nodosum lesion.

There is some difference of opinion as to how the lesions are pro­
duced—whether the disease is an angioneurosis (Lewin), the cutaneous
phenomena resulting, as in erythema multiforme, or an inflammation
of the lymphatics (Hebra), or due to embolism (Bohn, Panum).

From anatomic investigations made (Lewin, Kaposi, Campana,
Phillipson, Jadassohn), the inflammatory character of the process is

¹ Lendon, in his recent work, “Nodal Fever; Synonyms—Erythema Nodosum,
Erythema Multiforme,” London, 1905, holds this view strongly, but one must confess
that as yet the evidence is not conclusive.

² Marfan, La Presse Medicate, June 26, 1909, p. 457 (abstract in Brit. Jour. Derm.,
1909, p. 372), reiterates the belief in some relationship, briefly reviews the subject, and
details some experimental observations (with references to important papers).

³Leviseur, “Erythema Nodosum Syphiliticum,” Jour. Cutan. Dis., 1911, p. 597,
reviews the literature, and thinks it indicates that there is conclusive evidence of
there being a syphilitic eruption resembling clinically both erythema nodosum and
erythema induratum.

⁴ Gibb, Lancet, April 23, 1898,

⁵ Glück, abstract in Monatshefte, 1898, vol. xxvii, p. 467.

⁶  Schein, ibid., vol. xxviii, 1899, p. 411.

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INFLAMMATIONS

disclosed. Dilatation of the blood-vessels and closely crowded cells
are to be noted in the corium and papillary layer, and in some instances
extravasations of blood or transudation of blood coloring-matter. Granu-
ular cell infiltration of connective-tissue bundles and cell collections pack­
ing the lymphatic vessels are also at times observed. In the blood-
vessels, particularly the veins, the leukocytes are sometimes so massed
that they have the aspect of white thrombi (Unna). Hoffmann found
phlebitis of the larger subcutaneous veins. In addition there is marked
serous infiltration in the cutaneous, and usually subcutaneous, tissues.
The epidermis rarely shares in the morbid process.

Diagnosis.—Erythema nodosum should not be confounded with
bruises, abscesses, gummata, and the lesions of erythema induratum,
to which it may, at times during its course, bear resemblance. If the
beginning bright red, rosy tint, with the later color changes, the appar­
ently violent character of the process, the number, the situation, and
course of the lesions, are borne in mind, an error in diagnosis is not
likely to occur. Bruises, abscesses, and gummata are rarely present
to a greater number than one or two or three. The course of the latter
two diseases is entirely different—the nodes of erythema nodosum
never break down, and the disease is frequently accompanied by rheu­
matic pains and swellings about the joints. The lesions of erythema
induratum are slower in their course, are usually dark in color in the
very beginning, soon show evidences of breaking down and of ulceration,
and are unaccompanied by any febrile and rheumatic symptoms. More­
over, this latter disease is usually seen in subjects with tuberculous tend­
encies.

Prognosis.—This is favorable, the disease usually running its
course in several weeks to one or two months. A few grave and fatal
cases have been reported (Demme, Schmitz, Lewin, and others), but there
always arises a question that these are examples of a general systemic
septic infection, of which the erythema nodosum is simply a symptom and
a part of an accidental complication. At all events, as met with in this
country, the disease, while in exceptional instances severe and even
temporarily alarming, as a rule gives rise to no anxiety, and always
ends in recovery. The condition of the heart should, however, be in­
vestigated, especially in cases associated with rheumatic symptoms.

Treatment.—For the most part the treatment of this disease is
symptomatic and expectant. Rest, relative or absolute, depending
upon the severity of the cases, should be enjoined. The diet should
be plain and unstimulating. A saline laxative and intestinal anti­
septics and alkalis are most commonly prescribed. Full doses of
quinin are useful in some cases. Duhring especially indorses the value
of sodium salicylate and quinin. As a rule, an occasional saline laxative,
with sodium salicylate or sodium benzoate, and moderate doses of quinin,
constitute the essence of the treatment.

In some instances the tender and painful character of the cutaneous
lesions will demand external treatment. Lead-water and laudanum,
and 3 to 10 per cent, ichthyol ointments, may be used for this
purpose.

ERYTHEMA INDURATUM

l65

The rheumatic swellings and pains often about the joints will also
require at times similar soothing applications; the parts may also be
enveloped with cotton batting.

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