A 3-year-old girl presented to A
þ E with a 1 week history of general flu-like illness and a 1 day history of painful erythematous nodules on her shins. She had no significant past medical history. Her grandfather had previously had HSP but there was no other family history. There was no history of foreign travel and she was not in regular contact with animals. On examination she was miserable and pale but well-nourished and refusing to weight-bear. She screamed if anyone went near her legs. The rest of the examination was normal.
Blood tests showed raised inflammatory markers: CRP 107, WCC 21, Neutrophils 15.5. CXR was unremarkable.
Q1. What is this rash?
a) HenocheSchonlein purpura
b) Chicken Pox
c) Discoid eczema
d) Erythema nodosum
e) Erythema multiforme
Q2. What are the causes of this rash?
a) Inflammatory Bowel Disease
b) Streptococcal infection
c) Sarcoidosis
d) Campylobacter
e) Salmonella
Q3. Choose True or False for the following statements:
a) These lesions leave scars
b) They may continue to erupt for 10 days
c) The lesions usually resolve within a week
d) The lesions are prone to ulceration
e) It is a disorder of the subcutaneous fat
answer
A1 d) This rash is Erythema nodosum. It is a type of pan-niculitis. There is often no obvious cause. The most common cause in children is a streptococcal infection, specifically group A streptococcus secondary to tonsillitis. The nodules can appear 2e3 weeks after a streptococcal throat infection.
This child was treated with IV Augmentin and within 2 days the rash started to fade and the pain eased. A throat swab grew Group A Streptococcus.
A2 a,b,c,d,e) Causes: Streptococcal infection Sarcoidosis
Inflammatory Bowel Disease Pregnancy Tuberculosis Chlamydia
Mycoplasma pneumoniae Yersinia enterocolitica Salmonella Campylobacter
Drug reaction: antibiotics or the combined oral contraceptive pill
Lymphoma and leukaemia
Erythema nodosum is rare. It affects between two and three people in every 10,000 people per year in the UK. It is most common between the ages of 20 and 35 but it can occur at any age.
Usually the first sign of erythema nodosum is flu-like symptoms.
This happens before the nodules appear and may make a child feel generally unwell for a few weeks. Possible symptoms include a fever, a cough and even weight loss. They may also have aching joints, stiffness and general aches and pains. Their joints may become swollen. Ankle, knee and wrist joints are most commonly affected but any joint can be painful. Aching legs and joints can last for a number of weeks, or even months, after the nodules have appeared.
The nodules (rounded lumps) that occur in erythema nodosum can measure between two to six centimetres across. The shins are the most common site. Other common sites are on the arms, thighs and trunk but nodules can occur anywhere on the body.
Each nodule tends to last for about 2 weeks but new nodules can continue to appear for up to 6 weeks. When the nodule first appears it is usually red, hot and firm to the touch. As the nodule begins to fade, it looks more like a bruise, turning blue and then yellowish. It usually takes some weeks for the nodules to heal completely. They do not leave any scarring
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