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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 11  |  Issue : 3  |  Page : 326-328

Erythema induratum of bazin – Skin lesions with pyrexia of unknown origin undiagnosed for 4 years


Department of General Medicine, Nizar Hospital, Malappuram, Kerala, India

Date of Submission05-May-2022
Date of Decision01-Jun-2022
Date of Acceptance17-Jul-2022
Date of Web Publication12-Sep-2022

Correspondence Address:
Mansoor C Abdulla
Department of General Medicine, Nizar Hospital, Valanchery, Malappuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_67_22

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  Abstract 


Erythema induratum of Bazin is characterized by chronic, tender, erythematous, indurated subcutaneous nodules on the lower extremities caused by tuberculin hypersensitivity. A 21-year-old woman presented with recurrent episodes of multiple erythematous scaly lesions over both lower limbs below the knee and low-grade fever for 4 years. She was treated from various outside hospitals with multiple courses of antibiotics and nonsteroidal anti-inflammatory drugs without improvement. The histopathology of the skin lesion was suggestive of erythema induratum. She had complete resolution of her skin lesions and fever following 6 months of treatment with antitubercular drugs. A delay in the diagnosis of rare presentations of tuberculosis can result in the administration of ineffective and potentially damaging treatments.

Keywords: Erythema induratum of Bazin, pyrexia of unknown origin, skin lesions


How to cite this article:
Abdulla MC. Erythema induratum of bazin – Skin lesions with pyrexia of unknown origin undiagnosed for 4 years. Int J Mycobacteriol 2022;11:326-8

How to cite this URL:
Abdulla MC. Erythema induratum of bazin – Skin lesions with pyrexia of unknown origin undiagnosed for 4 years. Int J Mycobacteriol [serial online] 2022 [cited 2022 Nov 26];11:326-8. Available from: https://www.ijmyco.org/text.asp?2022/11/3/326/355922




  Introduction Top


Cutaneous tuberculosis (TB) is rare, which accounts for 1%–1.5% of all extrapulmonary TB manifestations and 8.4%–13.7% of all TB cases.[1] Erythema induratum of Bazin (EIB) is a rare form of cutaneous TB that presents usually with recurrent episodes of skin lesions in the absence of systemic symptoms. We report a patient who had EIB and presented with recurrent episodes of low-grade fever and skin lesions for 4 years.


  Case Report Top


A 21-year-old woman presented with recurrent episodes of multiple skin lesions over both lower limbs below the knee and low-grade fever for 4 years. She had no medical illness in the past and had no addictions. She denied a history of high-risk behavior and had no sick contacts. On examination, multiple ill-defined erythematous scaly plaques and nodules were present over the anterior and posterior aspects of lower limbs below the knee which were mildly tender [Figure 1]a. Few lesions showed surface atrophy. There was no discharge, ulceration, or scarring. The rest of the examination was unremarkable.
Figure 1: Clinical photograph of skin lesion (a). Histopathological examination of the skin showed lobar panniculitis with focal noncaseous necrosis, vasculitis, and granulomas (b-d). Ziehl–Neelsen stain showed no acid-fast bacilli and Grocott methenamine silver stain showed no fungal elements (e and f)

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Hemoglobin was 12.9 g/dl, total leukocyte count – 6,450/ml, platelet count – 2, 76,000/microliter, and erythrocyte sedimentation rate – 36 mm in 1h. Biochemical parameters were normal. HIV, hepatitis B, and hepatitis C serology were negative. The chest X-ray was normal. Antinuclear antibodies, antineutrophil cytoplasmic antibodies, serum angiotensin-converting enzyme, and serum C3 and C4 complement levels were normal. The Mantoux test was strongly positive. Her blood culture was negative twice. Histopathological examination of the skin showed lobar panniculitis with focal noncaseous necrosis, vasculitis, and granulomas [Figure 1]b,[Figure 1]c,[Figure 1]d. Ziehl–Neelsen stain showed no acid-fast bacilli, and Grocott methenamine silver stain showed no fungal elements [Figure 1]e and [Figure 1]f. Cartridge-based nucleic acid amplification test of the skin biopsy specimen for TB was negative. The histopathology was suggestive of erythema induratum. She was started on antitubercular treatment (isoniazid 300 mg, rifampicin 450 mg, pyrazinamide 1 g, and ethambutol 800 mg daily). She had complete resolution of her skin lesions and fever following 6 months of treatment with antitubercular drugs.


  Discussion Top


Cutaneous TB represents 1.5% of all cases of extrapulmonary TB.[1] Cutaneous TB has various clinical manifestations including lupus vulgaris (LV), scrofuloderma, TB verrucosa cutis, orificial TB, tuberculous gumma, tuberculous chancre, and acute cutaneous miliary TB.[2] The most common form of cutaneous TB is LV.[3] A tuberculid is a cutaneous immunologic reaction to the presence of TB, which is often occult, elsewhere in the body.[4] The various forms of tuberculids include lichen scrofulosorum, papulonecrotic tuberculids, EIB, and erythema nodosum.[5]

EIB is characterized by chronic, tender, erythematous, indurated subcutaneous nodules on the lower extremities caused by tuberculin hypersensitivity.[6] EIB is a type of hematogenous cutaneous TB and is the most common form of cutaneous TB seen in Asia.[6] EIB is commonly seen in young- or middle-aged women.

EIB usually causes recurrent episodes of violaceous nodules or deep-seated plaques on the posterior and anterolateral aspects of the legs which are not painful and have a tendency for central ulceration.[7] The lesions spontaneously resolve within a few months but may cause postinflammatory hyperpigmentation or atrophic pigmented scars.[8] The disease typically runs a chronic course with relapsing episodes every 3–4 months without any accompanying systemic symptoms.[8]

Our patient had episodes of skin lesions and fever for 4 years which was treated from various outside hospitals with multiple courses of antibiotics and nonsteroidal anti-inflammatory drugs without improvement. She had complete resolution of the lesions and fever following 6 months of treatment with antitubercular drugs. EIB is usually not associated with any other systemic symptoms, but our patient had a long-standing low-grade fever which improved with antitubercular drugs. The fever in our patient was probably due to EIB (other infective and noninfectious causes were ruled out by appropriate tests).


  Conclusion Top


A delay in the diagnosis of rare presentations of TB can result in the administration of ineffective and potentially damaging treatments. We describe a patient with EIB who presented with recurrent episodes of low-grade fever which was not reported previously.

Authors' contribution

MCA-clinical analysis, writing the manuscript, clinical analysis, and critically revising and approving the manuscript.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Acknowledgment

I would like to thank Dr. Asik siddik of pathology whose comments and suggestions were immensely valuable for improving this case report.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Maghwal N, Jain VK, Chouhan C, Rao P, Choudhary P. A clinicopathological pattern of cutaneous tuberculosis and HIV concurrence in western Rajasthan. Int J Mycobacteriol 2020;9:429-34.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Gunawan H, Achdiat PA, Hindritiani R, Essary ED, Ningtias LD, Siregar EP, et al. Various cutaneous tuberculosis with rare clinical manifestations: A case series. Int J Mycobacteriol 2018;7:288-91.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Khare S, Chhabra N, Ganguly S, Prabha N. Sporotrichoid presentation of lupus vulgaris mimicking mycetoma. Int J Mycobacteriol 2019;8:292-4.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Kajal NC, Prasanth P, Dadra R. Lichen scrofulosorum: An uncommon manifestation of a common disease. Int J Mycobacteriol 2020;9:313-5.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Rakhesh SV, Moideen Hidayathullah PK, Khader A, Uvais NA. Lichen scrofulosorum: Cutaneous manifestation of tuberculous lymphadenitis. Int J Mycobacteriol 2021;10:469-71.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Yang K, Li T, Zhu X, Zou Y, Liu D. Erythema induratum of Bazin as an indicative manifestation of cavitary tuberculosis in an adolescent: A case report. BMC Infect Dis 2021;21:747.  Back to cited text no. 6
    
7.
Babu AK, Krishnan P, Dharmaratnam AD. Erythema induratum of Bazin-tuberculosis in disguise. J Dermatol Dermatol Surg 2015;19:66-8.  Back to cited text no. 7
    
8.
von Huth S, Øvrehus AL, Lindahl KH, Johansen IS. Two cases of erythema induratum of Bazin – A rare cutaneous manifestation of tuberculosis. Int J Infect Dis 2015;38:121-4.  Back to cited text no. 8
    


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