Kalyani Pillai*, Sandhya Acharya, S Criton, Parvathy VK*
Department of Pediatrics* & Department of Dermatology, Amala Institute of Medical Sciences, Thrissur, Kerala , India

Address for Correspondence: Dr Kalyani Pillai, Santhwanam Mallika Gardens, Chittilapilly PO, Thrissur, Kerala 680551. Email: drkalyani@sancharnet.in

Erythema Nodosum (EN) due to tuberculosis is now becoming increasingly rare. In the West, streptococcal infection is the common cause for EN. However in tuberculosis, EN may the only manifestation of a primary pulmonary infection or may be found in patients with positive Mantoux skin test but no detectable focus of tubercular infection. We present such a case.

Keywords: Erythema nodosum, tuberculosis

A 10 years old boy from Malappuram district, Kerala came with history of recurrent episodes of painful red nodular lesions over ears, upper & lower limbs of 2-3 months duration. There was no other significant history and no contact with tuberculosis (TB) patient. Child was unimmunized. On examination he was well nourished and systemic examination was normal. The skin lesions were suggestive of Erythema Nodosum (EN). Investigations showed ESR of 58mm at end of one hr and Mantoux test was >20mm. X-ray chest was suggestive of primary complex. Anti Streptolysin O was negative. Skin biopsy confirmed diagnosis of EN. Child was treated with Category III treatment for TB as per Revised National Tuberculosis Control Programme (RNTCP) India. The EN resolved and did not recur.

EN may be associated with a wide variety of disease processes such as infections, drugs, malignant diseases, and a wide group of miscellaneous conditions (1,2). Although there are considerable geographic variations related to endemic infections, in the West streptococcal infections are the most frequent etiologic factor for EN in children (3). TB is now an uncommon etiologic factor for EN in the West but it has been linked with EN (1-5). TB induced EN are seen usually in children and the EN lesions usually indicate a primary pulmonary infection, being concomitant with the conversion of the tuberculin test (5) as was seen in our patient. EN may even manifest before the development of a skin-test reaction to tuberculin. Furthermore, EN may be found in patients with highly positive reactions to the Mantoux skin test but no detectable focus of tubercular infection. Antitubercular therapy should be initiated for EN in patients with positive Mantoux skin test reactions with or without a positively identified focus of infection. (5,6) as treatment may lead to cure and non-recurrence as was seen in our patient.

Financial Disclosure: Nil
Conflict Of Interest: Nil

	1.	Fox MD, Schwartz RA. Erythema nodosum. Am Fam Physician. 1992; 46: 818-822.
	2.	Kakourou T, Drosatou P, Psychou F, Aroni K, Nicolaidou P. Erythema nodosum in children: a prospective study. J Am Acad Dermatol. 2001; 44: 17-21.
	3.	Cribier B, Caille A, Heid E, Grosshans E. Erythema nodosum and associated diseases. A study of 129 cases. Int J Dermatol. 1998; 37: 667-672.
	4.	Mert A, Ozaras R, Tabak F, Ozturk R. Primary tuberculosis cases presenting with erythema nodosum. J Dermatol. 2004; 31: 66-68.
	5.	Kumar B, Sandhu K. Erythema nodosum and antitubercular therapy. J Dermatolog Treat. 2004; 15: 218-221.
	6.	Brodie D, Schluger NW. The diagnosis of tuberculosis. Clin Chest Med. 2005; 26: 247-271.

Last updated:1^st April 2009. Volume 6 Issue 4 Art # 18

Pillai K, Acharya S, Criton S, Parvathy VK. Lest we Forget - Tuberculosis. Pediatric Oncall. [serial online] 2009 [cited 2009 April 1];Vol 6, Art # 18. Available from:
http://www.pediatriconcall.com/fordoctor/casereports/lest_we_forget.asp