J7Accid Emerg Med 1996;13:211-212 211

CASE REPORTS J Accid Emerg Med: first published as 10.1136/emj.13.3.211 on 1 May 1996. Downloaded from nodosum diagnostic difficulties in the accident and emergency department

Patrick Hyland-McGuire, Henry Guly

Abstract The next day a "" was noted on the Five patients presenting with erythema right amputation stump. The original in- nodosum to an accident and emergency flammation initially improved but over the department are described. Initially they next 7 d red patches appeared over both thighs, were misdiagnosed as , infected left elbow, left hand, and neck. A diagnosis of insect bites, and minor trauma. Sus- was made and this was picious skin lesions or joint manifestations confirmed by a dermatologist. A chest x ray occurring either alone or especially if in showed hilar lymphadenopathy. Antistrepto- combination should alert the wary lysin-O titre was normal. A clinical diagnosis of clinician to the possibility of erythema was made. Follow up one month nodosum and follow up in a few days may later revealed residual bruising over the area of help to confirm the diagnosis. the lesions. (_JAccid Emerg Med 1996;13:21 1-212) CASES 2-5 Key terms: erythema nodosum; diagnosis; misdiagnosis Four further cases are summarised in the table. Erythema nodosum is an uncommon skin eruption' which may be a marker ofunderlying Discussion systemic disease. Clinical recognition should Erythema nodosum classically presents as prompt investigation into possible causes, bilateral, painful, red, tender nodules of some of which are serious and amenable to varying size and number on the anterior shins.4 treatment. In its early stages, the condition Much less commonly, lesions occur on the may mimic soft tissue infections2 or sub- backs of the legs, thighs, soles ofthe feet, arms, acute musculoskeletal conditions,3 which are and neck. Nodules may not necessarily be commonly seen in accident and emergency symmetrical and may appear at different http://emj.bmj.com/ (A&E) departments. We report on five patients times.5 Areas may become confluent and with erythema nodosum who were initially appear as a single lesion. Erythema nodosum misdiagnosed in the A&E department is commonest in the third to fifth decade, with a female to male predominance of 3:1. Case reports Erythema nodosum is associated with a wide CASE 1 spectrum of diseases and thorough in-

A 36 year old woman with a previous right vestigation has been reported to yield an on September 25, 2021 by guest. Protected copyright. below knee amputation following trauma underlying cause in 67-5% to 95% of cases.6 presented to the A&E department with a one Associated conditions include sarcoidosis, week history of pain in her left leg with redness streptococcal infection, , histo- extending from the ankle to the knee which had plasmosis, other infections such as yersinia, failed to respond to flucloxacillin prescribed by mycoses, chlamydia and lymphogranuloma her family doctor. This was initially diagnosed venereum, drugs (for example, oral contra- as cellulitis. She was admitted under the A&E ceptives and sulphonamides), service for rest, elevation, and intravenous and Crohn's disease, and neoplasms such as flucloxacillin and benzylpenicillin. Hodgkin lymphoma and leukaemia. The

Clinical details offourfurther cases oferythema nodosum Case Sex Age Presenting symptoms Initial diagnosis Initial treatment Subsequent history Underlying (years) cause 2 F 31 Pain right hip and knee Minor trauma Nil 2 d: 5 nodules right lower Sarcoidosis Red right knee limb 1 nodule left lower limb Accident and Increased pain 3 M 36 Redness and swelling left Cellulitis Admitted for IV 2 d: Pain and Sarcoidosis Emergency shin (also bilateral antibiotics both shins Department, Achilles tendinitis) Derriford Hospital, 4 M 9 "Insect bites" both shins Insect bites both Chlorpheniramine, 2 d: Pain left ankle None found Plymouth PL6 8DH, Left worse than right shins flucloxacillin ESR: 68 mm/hour United Kingdom Pyrexia 39'C Left side infected P Hyland-McGuire 5 F 43 Pain left wrist with a red Non-specific Ibuprofen/splint 2 d: 8 nodules left shin None found H R area over joint inflammation diagnosed as insect bites Guly Flucloxacillin 4 d: nodules right shin Correspondence to: Mr Patrick Hyland-McGuire IV, intravenous 212 J7Accid Emerg Med 1996;13:212-213

condition may also occur in association with areas. The diagnosis should also be considered streptococcal cellulitis.4 This sequence was in patients with arthralgia and synovitis, J Accid Emerg Med: first published as 10.1136/emj.13.3.211 on 1 May 1996. Downloaded from initially suspected in one of our patients especially if affecting typical joints. If erythema (case 1) but subsequently this patient was nodosum is strongly suspected, the patient shown to have sarcoidosis. There is no should have a chest x ray and should be evidence that antibiotics have an adverse effect referred to the medical service at the time on the course of erythema nodosum. of presentation for further management. The skin lesions of erythema nodosum are However, if a classical pattern is not often preceded or accompanied by fever, recognised, it would be useful to review the , and arthralgia. These symptoms are a patient again in the A&E department in two or feature of the underlying condition, and three days, at which time more classical erythema nodosum may be considered a skin features may have evolved. The patient should marker of the process. Joint manifestations be advised to return to the A&E department in occur in 75% of cases, with arthralgia being the interim should the skin lesions progress. It more common than synovitis. The synovitis is may be necessary to treat the condition as a self limiting and non-erosive and symmetrically cellulitis until features of erythema nodosum affects the knees and ankles and less commonly are recognised. the wrists, elbows, small joints of the hands, and shoulders in one third of patients with 1 O'Neill JH. The differential diagnosis of erythema nodo- erythema nodosum. The affected joints are sum. Delaware MedJ 1991;63:683-9. 2 Hebel JL, Snider RL, Mitchell D. Lofgren's syndrome. Cutis painful, stiff and tender, and an effusion is 1993;52:223-4. usually present. 3 Green GA, Maltz BA. Case report: bilateral ankle sprain in an aerobic dancer. Med Sci Sport Exerc 1992;24: 1316-20. There may be difficulty when the condition 4 Ryan TJ. Diseases ofthe skin. In: Weatherall DJ, Ledingham presents before a classical pattern has evolved. JGG, Warren DA, eds. Oxford textbook ofmedicine, 2nd ed. Oxford: Oxford University Press, 1987:16.55, 20.66, Erythema nodosum has previously been 20.67. reported as being misdiagnosed as cellulitis2 5 Sauer GC. Manual of skin diseases, 5th ed. Philadelphia: JB Lippincott Co, 1985:112. and soft tissue sarcoma.7 Any tender, red 6 Atanes A, Gomez N, Aspe B, de Toro J, Grana J, Sanchez nodule, especially on the shin, should be JM, et al. Erythema nodosum: a study of 160 cases. Med Clin 1991;96:169-72. carefully examined and a search made for 7 Siriwardena AK. Erythema nodosum minicking soft tissue lesions on the other side and on other typical sarcoma. BrJ Clin Pract 1990;44:515.

A confused drug addict: the importance of considering sepsis http://emj.bmj.com/

P Cornelius, E Pourgourides, S Meek

Abstract smashed up and the patient was acutely on September 25, 2021 by guest. Protected copyright. The case is reported of a 35 year old heroin disturbed, violent, and aggressive. addict presenting with acute confusion On examination in the A&E department, he which was later found to be due to men- was alert but disorientated in both time and ingococcal meningitis. Other than his space and was aggressive and uncooperative. altered mental state, the only abnormal General physical examination was unremark- finding on examination was a mild pyrexia. able apart from the presence of a mild pyrexia (_Accid Emerg Med 1996;13:212-213) of 37 5°C; there was no focal neurological deficit, no neck stiffness, and no . Vene- Key terms: sepsis; heroin addiction; acute confusion puncture was difficult because of his intra- venous drug abuse and aggressive state. Case report Eventually a small sample was obtained which A 35 year old male who is a registered heroin was sent for a full blood count. This showed addict was brought by ambulance to the a haemoglobin concentration of 1 64 g/litre Accident and accident and emergency (A&E) department at and a white count of 28-8 X 109/Ilitre, with 89% Emergency 11 pm, accompanied by his girlfriend, who had neutrophils. A diagnosis of toxic confusional Department, found him in an aggressive and confused state. state secondary to infection was made and he Frenchay Hospital, Bristol He was on a methadone replacement pro- was admitted for further investigation, includ- P Cornelius gramme and had taken his normal dose of ing computerised tomography brain scan and E Pourgourides methadone in the morning, together with a lumbar puncture. Because of continued S Meek small dose of intravenous heroin. He sub- agitation he required sedation and ventilation. Correspondence to: Dr P Cornelius, sequently went to college and returned at mid- Neisseria meningitidis was subsequently grown Accident and Emergency day complaining of a mild headache. His girl- from his blood cultures and CSF samples. Department, Bristol Royal Infirmary, Bristol BS2 8HW, friend then left him alone and returned in the Tests for HIV were negative. His inpatient stay United Kingdom. evening to find that the room had been was protracted and complicated by broncho-