ERYTHEMA NODOSUM Erythema nodosum is likewise an infectious disease, bears a close relationship to erythema exmlativum multiformc and often occurs in conjunction with it, but its course is generally somewhat more severe.
Clinical prodromal manifestations (discomfort, chills, pains in the limbs, slight elevation of temperature, etc.), nodules of a coarse, doughy consistency are formed in the deeper layers of the skin and in the fat tissue (sec Plate 61). They exhibit a bluish red discoloration, are painful on pressure, slightly raised, feel tense, and their size may increase to that of a hen's egg. They fir.st appear on the leg and the dorsal surface of the foot, and may spread to the trunk and forearms.
nodules which are subject to change as to their number and size, are gradually resorbed and (disappear, leaving a pig ment after having passed through the usual scale of colors during the resorption of extravasated blood. Although the number of the nodules is usually between eight and ten, they may increase by spasmodic attacks, in which case the course of the disease would be prolonged.
The nodules generally heal within two or three weeks, but in graver cases several months may pass before the trouble is completely subdued. The fever, which in light eases rises to 38°-39° C. (OS.S°-100.1° F.), May reach 41° C. 006° F.), it then gradually recedes—possibly to return again with a fresh attack. Often there are rheumatic pains, there may be vomiting, and the disease seems to present the picture of a severe infectious disease. In these cases hamlorrhagic nephritis, pleuritis, meningitis, endocarditis or pericarditis may develop. Trousseau and Amiaud have observed nodules on the mucous membranes of the lips, palate and fauces. Quite as frequently' the affection is said to occur relatively often during convalescence after various infectious diseases, as for instance scarlet fever.
The disease shows a predilection for youthful individuals, but it also occurs in nursing infants, although generally it occurs with greater frequency in more advanced years. Comby mentions 51 cases out of 67 who had passed the third year, while in 16 cases children under three years were attacked. It is equally surprising that the infection more frequently attacks girls. Among Comby's 67 eases 41 were females. In opposition to Kaposi's observation that the affection occurred chiefly in the spring and fall, Comby counted 36 cases from October to March and 31 cases from April to October. There is an interesting communication from Schultheiss calling attention to the frequent occurrence of this affection in Switzerland, his native country, where lie had studied it for twelve years, and also to the difference between the temperature curves of erythema nodosum and erythema exudativum multiforme, as against the surprising similarity of the scarlet fever curve and that of erythema nodosum.
Anatomy.—According to Neisser, erythema nodosum is a widely extended inflammation, localized in the connective and fat tissues. The vascular network of the cutis and papillary body is dilated and surrounded by strong infiltration. There is pronounced (edema and great blood extravasation into the tissue. Neisser compares this affection with a limmorrhagic infarct.
Etiology.—Erythema nodosum is an infectious disease, the virus of which is as yet unknown. Its infecting capacity is comparatively small, as otherwise more small epidemics would surely have become known. Isolated cases of infection from child to child have been de scribed by Para and Moussous, while Abaft reported a case of a family epidemic, in WhiCh SCVell children out of nine in one family suffered from erythema nodosum complicated by pneumonia, typhoid, etc. Why erythema should sometimes occur during the convalescent period of scarlet fever, etc., is unknown to us.
Differential Diagnosis.—The diagnosis of erythema nodosum is comparatively easy. It is easily differentiated from boils through the folliculitis which in the latter affection is recognizable in the beginning of the disease, and later through the ulceration. Syphilitic gummata take a chronic course, so does the pathological picture designated by Bazin as erythema indure. It can also easily be distinguished from eminences caused by contusion.
Prognosis.—The prognosis is generally favorable. Here again I cannot help feeling that a large percentage of the reported unfavorable cases belong to general septic conditions complicated by secondary erythema, and not to erythema itself.
treatment follows that of erythema multiforme. Rest in bed should be prescribed and raising the lower extremities as soon as the nodules appear. In gastric disturbances special diet and laxatives are indicated. The patient gratefully appreciates lukewarm baths once or twice a clay. By way of internal treatment salicylic prep arations may- be given with a view to cleansing the intestine. To this end Boeck recommends antifebrin. The local treatment has to confine itself to reducing the inflammation by cold compresses and to affording protection to the nodules by the application of zinc glue (Leistikow) or ichthyol collodium CI:nna). Rheumatoid or articular pains are best treated by salicyl.