cqvip:A 53-year-old Greek housewife was admitted to hospital because of painful erythematous lesions on the lower (Fig. 1) and upper (Fig. 2) extremities in association with painful ocular hyperemia. These symptoms were preceded by an upper respiratory infection with persistent high-grade fever for about 1 week. Erythematous lesions had appeared 3 days previous to admission. Her medical history included two previous episodes of erythema nodosum (unknown etiology), essential hypertension treated with perindopril 4 mg/day, diabetes mellitus type II under diet only, and multinodular goiter under treatment with thyroxine 0.1 mg/day. Examination of the skin revealed tender, violet-red, subcutaneous erythematous nodules, measuring 2- 3 cm in diameter, located on the anterior and posterior surfaces of the legs (Fig. 1), and tender, violaceous papulo-vesicular lesions located on the face and forearms (Fig. 2). Ocular examination revealed diffuse anterior scleritis. Laboratory tests gave the following values: white blood cell count, 12,600cells/mm3 (neutrophils 78% , lymphocytes 16% , and monocytes 4% ); erythrocyte sedimentation rate (ESR), 109 mm/h; C-reactive protein (CRP), 13 mg/dL (normal range: 0.08- 0.8 mg/dL); normal biochemical parameters and urinalysis. An electrocardiogram, chest X-ray, gastroscopy, colonoscopy and abdominal ultrasound scan were within normal limits. The antistreptolysin (ASTO) level and thyroid function tests gave results within the normal range. A tuberculin skin test, and immunological and serologicall tests, such as tests for viruses, were negative. Histological examination of a biopsy specimen obtained from an erythematous nodule on the left leg showed panniculitis involving inflammation of the septa in the subcutaneous fat tissue without signs of vasculitis. Histopathology of a biopsy specimen obtained from a lesion on the right forearm revealed remarkable inflammatory neutrophilic (predominantly) infiltration throughout the entire dermis admixed with some mononuclear cells (lymphocytes and histiocytes) and sparse eosinophils. Endothelial cells of small vessels showed swelling, without signs of vasculitis. Papillary dermis was edematous (Fig. 3a and b). The patient was treated with prednisolone (initial dose 0.5 mg/kg for 1 week), reduced gradually and suspended after 4 weeks. Five days after the initiation of treatment, the skin lesions vanished and ocular manifestations improved. Leukocyte and neutrophil counts, ESR and CRPreturned to normal on suspension of therapy. There was no recurrence at follow-up 6 months and 1 year later.
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