Erythema induratum: a clinicopathologic and polymerase chain reaction study

In Taiwan, cutaneous lesions with granulomatous lobular panniculitis, with or without vasculitis, are usually diagnosed as erythema induratum (EI), a common form of tuberculid associated with tuberculosis. However, there has been no study to elucidate the extent of this association in Taiwan. The aim of this study was to document the spectrum of the pathologic findings in EI and its association with Mycobacterium tuberculosis.

The diagnostic/inclusion criteria for EI were recurrent tender subcutaneous nodules on the legs, histopathologic findings of granulomatous lobular or septolobular panniculitis plus necrosis or vasculitis, and positive response to antituberculosis therapy. The clinicopathologic findings in the 12 cases that fulfilled these criteria were analyzed, and nested polymerase chain reaction (PCR) was used to identify M. tuberculosis complex DNA from formalin-fixed, paraffin-embedded sections.

Eleven women and one man were included in the study, ranging from 18 to 70 years old (mean, 40.6 yr). The duration of the disease ranged from 10 days to 10 years (mean, 2.1 yr). Histopathology revealed granulomatous panniculitis; a diffuse lobular pattern was observed in nine cases and a focal lobular/septolobular pattern in three. Vasculitis was found in nine cases, four affecting an artery or vein, with three occurring in the patients with focal panniculitis. Ten cases showed various degrees of caseous necrosis. Eosinophils or focal eosinophilia were fairly common (10 patients). From PCR, nine patients were positive for M. tuberculosis complex DNA.

Type III and IV hypersensitivity reactions to M. tuberculosis complex were involved in the pathogenesis of EI. Our results suggest that approximately half of the cases with pathologic findings consistent with EI or nodular vasculitis in Taiwan are associated with M. tuberculosis.