Erythema nodosum associated with reactivation tuberculous lymphadenitis (scrofula)
Erythema nodosum associated with reactivation tuberculous lymphadenitis (scrofula)
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DOI：
10.1046/j.1365-4362.2002.01390.x
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发表时间：
2002-03-01
影响因子：
3.6
通讯作者：
Shaw, JC
中科院分区：
文献类型：
--
作者：
Gupta, SN;Flaherty, JP;Shaw, JC
一位73岁的非裔美国女性来我们诊所就诊，持续2周的下肢疼痛皮损。在发病前3个月，她一直处于正常的健康状态，当她报告疲倦和虚弱的症状时，她还注意到左侧颈部肿块增大。她否认发烧、发冷、盗汗或咳嗽。她的症状对口服双氯西林一个疗程没有反应。颈部肿块增大超过8周，并被转介到我们机构进行评估。颈部CT扫描显示淋巴结肿大。在她提出皮肤科报告的前10天，对肿大的淋巴结进行细针抽吸发现坏死性肉芽肿。组织被送去进行常规的分枝杆菌和真菌培养。还进行了血常规、胸片和结核菌素皮肤试验。在皮肤科就诊时，她描述了双侧下肢出现多个新的疼痛、非瘙痒的皮损。她还报告说，在她的下肢病变发生后，她的结核菌素试验部位出现了一个红色结痂区域。她过去的病史对帕金森氏症、甲状腺功能减退和高血压有重要意义。她目前的药物包括L-甲状腺素、雌激素和地尔硫卓。她的旅行史只有在前一年春天的牙买加之旅中才引人注目。她在海地出生和长大。她在20年前报告了结核菌素皮肤试验阳性的病史，但没有接受治疗。体检显示左侧颈部肿块为2x3厘米结实，没有触痛(图1)。右前臂显示直径1.5厘米的红斑、溃烂、硬化斑块(图2)。她的双膝以下0.5-1厘米处有红斑结节(图3)，穿孔活检显示轻度真皮浸润性病变。皮下组织内可见间隔增宽。脂肪小叶间隔内也可见淋巴组织细胞渗出，并有少量中性粒细胞混杂。没有坏死性血管炎或胶原坏死的证据。没有进行抗酸染色。组织学结果与结节红斑的诊断一致。实验室检查包括血细胞计数、电解质、甲状腺检查、血管紧张素转换酶水平和胸部X线片均正常。皮肤学检查后约1周，细针吸取液培养出结核分枝杆菌。确诊为结核性淋巴结炎合并结节性红斑。患者开始接受异烟肼、利福平、乙胺丁醇和吡嗪酰胺的四联疗法。在接下来的一个月里，她的下肢皮肤病变迅速消失，她的颈部肿块也缩小了。她完成了6个月的抗结核治疗，淋巴结病完全消失。
A 73-year-old African American female presented to our clinic with painful lower extremity lesions of 2 weeks duration. She was in her usual state of health until 3 months prior to presentation when she reported symptoms of fatigue and weakness, She also noticed an enlarging mass on the left side of her neck. She denied fevers, chills, night sweats or cough. Her symptoms were unresponsive to a course of oral dicloxacillin. The neck mass enlarged over 8 weeks and she was referred to our institution for evaluation. CT scan of the neck showed an enlarged lymph node. Ten days prior to her presentation in dermatology, a fine needle aspirate of the enlarging lymph node revealed necrotizing granulomas. Tissue was sent for routine mycobacterial and fungal cultures. Routine blood work, chest radiograph, and a tuberculin skin test were also performed. At the time of her dermatology visit she described the development of multiple new painful, non-pruritic lesions, bilaterally on the lower extremities. She also reported a red crusted area that appeared at the site of her tuberculin test that was placed subsequent to the development of her lower extremity lesions.Her past medical history was significant for Parkinson's disease, hypothyroidism and hypertension. Her current medications included L-thyroxine, estrogen and diltiazem. Her travel history was only remarkable for a trip to Jamaica the previous spring. She was born and raised in Haiti. She reported a history of a positive tuberculin skin test 20 years ago, but received no therapy.Physical examination revealed a 2 x 3 centimeter firm, nontender left lateral neck mass (Fig. 1). Her right forearm revealed an erythematous, ulcerated, indurated plaque 1.5 cm in diameter (Fig. 2.). Her lower extremities revealed tender 0.5 to 1 cm erythematous nodules below the knees bilaterally (Fig. 3).A punch biopsy of a lower extremity nodule revealed a mild pervisacular dermal infiltrate. Within the subcutaneous tissue there was septal widening. There was also a lymphohistiocytic infiltrate with a slight admixture of neutrophils within the septa of the fat lobules. There was no evidence of necrotizing vasculitis or collagen necrosis. An acid-fast stain was not performed. The histologic findings were consistent with a diagnosis of erythema nodosum.Her laboratory evaluation including CBC, electrolytes, thyroid studies, angiotensin converting enzyme level and chest radiograph were normal.Approximately 1 week after her dermatological evaluation, the fine-needle aspirate culture grew Mycobacterium tuberculosis. A diagnosis of tuberculous lymphadenitis associated with erythema nodosum was confirmed. The patient was started on quadruple therapy of isoniazid, rifampin, ethambutol and pyrazinamide. Her lower limb skins lesions rapidly resolved over the subsequent month and her neck mass also diminished in size. She completed 6 months of antituberculous therapy with complete resolution of her lymphadenopathy.