Association between erythema nodosum/erythema induratum of Bazin and Mycobacterium tuberculosis infection in Koreans

Background: Erythema nodosum and erythema induratum of Bazin are similar inflammatory diseases of the lower extremities. These are clinically distinguishable entities, though overlap can occur. Both diseases are reported to be related to Mycobacterium tuberculosis infection, but it is very difficult to identify Mycobacterium tuberculosis in skin lesions. Aim: This study aimed to develop a new nested polymerase chain reaction targeting the IS6110 insertion sequence of M. tuberculosis to improve the M. tuberculosis detection rate in skin lesions of erythema nodosum or erythema induratum of Bazin. Methods: From May 2016 to Jan 2018, 14 patients with clinically suspicious erythema nodosum or erythema induratum were enrolled in the study. Two cases were classified as erythema nodosum and 12 as erythema induratum. Individual patients were subjected to a 4-mm punch biopsy, and their venous whole blood was sampled immediately after diagnosis. Results: Eight patients were tested for M. tuberculosis using QuantiFERON, of which seven (87.5%) were positive. IS6110-nested polymerase chain reaction on all 14 patients identified 11 (78.6%) positive cases. Four of the eight (50%) individuals tested with QuantiFERON were also positive in the IS6110 nested polymerase chain reaction. The difference between the outcomes of the QuantiFERON and the IS6110-nested polymerase chain reaction tests was not statistically significant. There was also no significant agreement between the results of both assays. Sequencing the IS6110-nested polymerase chain reaction products showed a 97%–100% nucleotide sequence identity with the H37Rv genome. Conclusion: It is important to test for tuberculosis in patients with multiple tender subcutaneous nodules on their lower extremities in high-burden tuberculosis countries like Korea. Limitations: We need to register more suspicious patients to verify the association between erythema nodosum/erythema induratum of Bazin and M. tuberculosis. Furthermore, it is neces

Unusual recurrent skin lesions: Bazin's disease

A 46 year old Iraqi Kurd female patient was presented with recurrent round erythematous skin lesions on her upper and lower extremities mainly calves, lower abdomen, and buttock for 3 years. Routine laboratory investigations were unremarkable; however, based on strongly positive tuberculin skin test, positive interferon gamma release assay, histo-pathological findings and a response to anti-TB treatment, she was diagnosed with Erythem Induratum of Bazin (EIB). The patient was treated successfully with combination anti-TB drugs. The skin lesions disappeared after 2 months of the treatment. There was no recurrence of the lesions over a 6 month follow up period.

Eritema indurado de Bazin asociado a infección por Mycobacterium tuberculosis / Erythema induratum of Bazin associated to Mycobacterium tuberculosis infection

El eritema indurado de Bazin es poco frecuente en la edad pediátrica. Presentamos el caso de una niña de 12 años procedente de China remitida para estudio por sospecha de eritema nudoso de larga evolución y prueba de tuberculina positiva (20 mm). La paciente no presentaba otros síntomas. En la exploración física se observaban nódulos violáceos, localizados en ambas regiones pretibiales, pero también en ambas pantorrillas. La radiografía de tórax fue normal. Se obtuvo muestra para biopsia, que mostró una paniculitis de predominio lobulillar con presencia de granulomas. La detección de micobacterias mediante cultivo y reacción en cadena de la polimerasa en la muestra fue negativa. Se aisló Mycobacterium tuberculosis en una de tres muestras de jugo gástrico. Se trató con isoniacida, rifampicina, pirazinamida y etambutol con curación de las lesiones. Este caso resalta la importancia de sospechar eritema indurado en las formas atípicas de eritema nudoso y de investigar exhaustivamente la existencia de una tuberculosis activa en estos casos.

Erythema induratum of Bazin is uncommon in children. We report the case of a 12 year-old girl from China, referred by her pediatrician with long lasting lesions of erythema nodosum and a positive tuberculin skin test (20 mm). She had no other symptoms. Physical examination showed purple nodular lesions located on both legs, mostly on the pretibial areas but also on her calves. A chest X-ray was normal. A skin biopsy was obtained, showing granulomata and septolobular panniculitis. Attempts to identify Mycobacterium tuberculosis by culture and PCR were negative. M. tuberculosis was isolated in one of three gastric aspirate samples. She was treated with isoniazid, rifampin, pyrazinamide and ethambutol. There was complete remission of the lesions. This case highlights the importance of considering erythema induratum in atypical cases of erythema nodosum and the need to perform a thorough investigation in search of active tuberculosis.

Erythema Induratum of Bazin / 대한피부과학회지

Erythema induratum of Bazin (EIB) belongs to a group of diseases characterized by inflammatory nodules of the leg which primarily involve the lower legs. EIB is considered to be a reactive disorder related to several etiologic factors. In Korea, most dermatologists accept the tuberculosis as one of the most common etiology of EIB. As the number of EIB cases is decreasing in Korea in accordance with the decreased incidence of tuberculosis, EIB can be easily mistaken for any of the disease that produces chronic nodular eruptions on the legs. In Korea, important factors to make a correct diagnosis of EI include clinicopathologic observations coupled with the identification of hypersensitivity to tuberculous antigen and successful treatment of anti-tuberculous medication.

Application of the QuantiFERON(R)-TB Gold Test in Two Cases of Erythema Induratum of Bazin / 대한피부과학회지

Erythema induratum of Bazin is a chronic, nodular subcutaneous eruption usually occurring on the lower legs of young women. Erythema induratum of Bazin hasbeen regarded as a tuberculide, a hypersensitivity response to Mycobacterium tuberculosis. The pathogenesis of erythema induratum of Bazin associated with tuberculosis is still debatable because mycobacteria cannot be cultured from the skin lesions. QuantiFERON(R)-TB Gold test detects INF-gamma released by T cells in response to Mycobacterium tuberculosis-specific antigens, which offers an improved diagnostic test of latent tuberculosis infection. We experienced two cases of erythema induratum of Bazin, which showed normal chest X-ray and negative TB-PCR. However the QuantiFERON(R)-TB Gold test was positive which led us to a diagnosis of latent tuberculosis infection. Both patients were treated with anti-tuberculosis medications, which was followed by successful resolution of the skin lesions. Therefore, we report the application of the QuantiFERON(R)-TB Gold test for the confirmation of latent tuberculosis infection in erythema induratum of Bazin patients.

Application of the QuantiFERON(R)-TB Gold Test in Two Cases of Erythema Induratum of Bazin / 대한피부과학회지

Erythema induratum of Bazin is a chronic, nodular subcutaneous eruption usually occurring on the lower legs of young women. Erythema induratum of Bazin hasbeen regarded as a tuberculide, a hypersensitivity response to Mycobacterium tuberculosis. The pathogenesis of erythema induratum of Bazin associated with tuberculosis is still debatable because mycobacteria cannot be cultured from the skin lesions. QuantiFERON(R)-TB Gold test detects INF-gamma released by T cells in response to Mycobacterium tuberculosis-specific antigens, which offers an improved diagnostic test of latent tuberculosis infection. We experienced two cases of erythema induratum of Bazin, which showed normal chest X-ray and negative TB-PCR. However the QuantiFERON(R)-TB Gold test was positive which led us to a diagnosis of latent tuberculosis infection. Both patients were treated with anti-tuberculosis medications, which was followed by successful resolution of the skin lesions. Therefore, we report the application of the QuantiFERON(R)-TB Gold test for the confirmation of latent tuberculosis infection in erythema induratum of Bazin patients.