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Based on the physical exam findings, the FP diagnosed erythema nodosum (EN) in this patient. He considered doing a punch biopsy down to the fat to prove that this was a panniculus, but realized that this was a classic presentation of EN. The lesions of EN are deep-seated nodules that may be more easily palpated than visualized. These lesions are initially firm, round or oval, and poorly demarcated. As seen in this case, the lesions may be bright red, warm, and painful.
The FP sought to consider the cause, and questioned the patient further about medications and other symptoms; however, he was unable to uncover any likely “suspects.” He then drew labs for a complete blood count, comprehensive metabolic panel, and uric acid and QuantiFERON TB gold tests. He started the patient on ibuprofen 400 mg tid with meals for the pain and inflammation.
On a follow-up visit 2 weeks later, all of the lab results were normal and the patient was about 50% improved. At this time, the FP obtained a chest x-ray to look for any evidence of sarcoidosis. The x-ray was also normal. (About half of all cases of EN are idiopathic, so the normal results were not surprising.) By the third visit the patient was 90% better and was happy to keep taking the ibuprofen to see if this would resolve completely.
After 6 weeks of treatment, there were no more tender erythematous nodules. All that remained was some postinflammatory hyperpigmentation. The patient was happy with these results and understood that she should return if the EN came back.
Photo courtesy of Hanuš Rozsypal, MD, and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ, Diaz L, Paulis R. Erythema nodosum. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1169-1173.
To learn more about the 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/
You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com
Based on the physical exam findings, the FP diagnosed erythema nodosum (EN) in this patient. He considered doing a punch biopsy down to the fat to prove that this was a panniculus, but realized that this was a classic presentation of EN. The lesions of EN are deep-seated nodules that may be more easily palpated than visualized. These lesions are initially firm, round or oval, and poorly demarcated. As seen in this case, the lesions may be bright red, warm, and painful.
The FP sought to consider the cause, and questioned the patient further about medications and other symptoms; however, he was unable to uncover any likely “suspects.” He then drew labs for a complete blood count, comprehensive metabolic panel, and uric acid and QuantiFERON TB gold tests. He started the patient on ibuprofen 400 mg tid with meals for the pain and inflammation.
On a follow-up visit 2 weeks later, all of the lab results were normal and the patient was about 50% improved. At this time, the FP obtained a chest x-ray to look for any evidence of sarcoidosis. The x-ray was also normal. (About half of all cases of EN are idiopathic, so the normal results were not surprising.) By the third visit the patient was 90% better and was happy to keep taking the ibuprofen to see if this would resolve completely.
After 6 weeks of treatment, there were no more tender erythematous nodules. All that remained was some postinflammatory hyperpigmentation. The patient was happy with these results and understood that she should return if the EN came back.
Photo courtesy of Hanuš Rozsypal, MD, and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ, Diaz L, Paulis R. Erythema nodosum. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1169-1173.
To learn more about the 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/
You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com
Based on the physical exam findings, the FP diagnosed erythema nodosum (EN) in this patient. He considered doing a punch biopsy down to the fat to prove that this was a panniculus, but realized that this was a classic presentation of EN. The lesions of EN are deep-seated nodules that may be more easily palpated than visualized. These lesions are initially firm, round or oval, and poorly demarcated. As seen in this case, the lesions may be bright red, warm, and painful.
The FP sought to consider the cause, and questioned the patient further about medications and other symptoms; however, he was unable to uncover any likely “suspects.” He then drew labs for a complete blood count, comprehensive metabolic panel, and uric acid and QuantiFERON TB gold tests. He started the patient on ibuprofen 400 mg tid with meals for the pain and inflammation.
On a follow-up visit 2 weeks later, all of the lab results were normal and the patient was about 50% improved. At this time, the FP obtained a chest x-ray to look for any evidence of sarcoidosis. The x-ray was also normal. (About half of all cases of EN are idiopathic, so the normal results were not surprising.) By the third visit the patient was 90% better and was happy to keep taking the ibuprofen to see if this would resolve completely.
After 6 weeks of treatment, there were no more tender erythematous nodules. All that remained was some postinflammatory hyperpigmentation. The patient was happy with these results and understood that she should return if the EN came back.
Photo courtesy of Hanuš Rozsypal, MD, and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ, Diaz L, Paulis R. Erythema nodosum. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1169-1173.
To learn more about the 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/
You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com
