Erythema Induratum of Bazin and Ponçet's Arthropathy as Epiphenomena of Hepatic Tuberculosis

Abstract

A 42-year-old black woman presented with fever, polyarthritis, livedo reticularis, subcutaneous calf nodules and hepatomegaly. She had been diagnosed with depression 6 weeks prior. Blood analysis showed anaemia, elevated erythrocyte sedimentation rate and C reactive protein, elevated liver enzymes, and positive antinuclear and antiribonucleoprotein antibodies. Abdominal ultrasound revealed heterogeneous hepatomegaly with necrotic lymphadenopathy around the caeliac trunk and splenic hilum. We considered the following diagnoses: lymphoma, connective tissue disease, tuberculosis and sarcoidosis. Subcutaneous nodule histology was compatible with erythema induratum of Bazin, and liver biopsy evidenced granulomatous hepatitis. Although microbiological examinations were negative in tissue samples, a presumptive diagnosis of hepatic tuberculosis was admitted. Having excluded other causes, erythema of Bazin, livedo reticularis and polyarticular involvement (Ponçet's arthropathy) were accepted as immunological epiphenomena associated with tuberculosis. Empirical antituberculous treatment was started and after 3 weeks the patient improved substantially. This clinical response was a further confirmation of the diagnosis.

Figure 1

Abdominal CT scan: contrast-enhanced hepatic heterogeneity; 1–2 cm multiple necrotic lymphadenopathy in the hepatic and splenic hila.

Figure 2

Cutaneous nodule biopsy (H&E stain): predominantly lobular panniculitis with lymphohistiocytic infiltrate consisting of giant multinucleated cells, neutrophils, eosinophils and extensive lipophagic fat necrosis. There is also infiltration of the lobular vessel walls with lymphocytes and neutrophils. These findings of lobular granulomatous panniculitis with neutrophilic vasculitis are consistent with erythema induratum of Bazin.

Figure 3

Cutaneous nodule biopsy (H&E stain): predominantly lobular panniculitis with lymphohistiocytic infiltrate consisting of giant multinucleated cells, neutrophils, eosinophils and extensive lipophagic fat necrosis. There is also infiltration of the lobular vessel walls with lymphocytes and neutrophils. These findings of lobular granulomatous panniculitis with neutrophilic vasculitis are consistent with erythaema induratum of Bazin.

Figure 4

Hepatic tissue biopsy: augmented portal space by granulomatous infiltration (periodic acid-Schiff stain).

Figure 5

Hepatic tissue biopsy: hepatic granulomas evidenced by Chromotrope-Aniline-Blue (CAB) staining.

Figure 6

Hepatic tissue biopsy: a detail of hepatic granuloma (CAB staining).