Skip to main content

Advertisement

SpringerLink
Log in

Erythema nodosum in children: a cohort study from a tertiary pediatric hospital in Italy

  • RESEARCH
  • Published:
European Journal of Pediatrics Aims and scope Submit manuscript

A Correction to this article was published on 02 March 2024

This article has been updated

Abstract

Erythema nodosum (EN), although relatively uncommon in the pediatric population, is the most frequent type of panniculitis in children. The present study aimed to report all the cases of children admitted to our tertiary pediatric hospital with the diagnosis of EN to evaluate the epidemiology, clinical manifestations, etiology, treatment, and the course of this disease in the pediatric age. This observational study retrospectively considered all children evaluated to the emergency room (ER) of Meyer Children’s University Hospital, Florence, Italy, discharged with a diagnosis of EN over a 12-year period (from January 2009 to December 2021). Clinical and laboratory data were recorded using a standardized report form. Sixty-eight patients with EN were included. The etiologic diagnosis of EN was made in 38 children (55.9%): 29 (42.6%) had infection-related EN (in particular EBV and β-hemolytic streptococcus), 6 (8.8%) had Crohn’s disease, 1 celiac disease, 1 Sjogren syndrome, and 1 Hodgkin lymphoma. In 30 patients (45%), no definitive diagnosis was reached, and they were defined as having idiopathic EN. Most of the laboratory tests were nonspecific. No statistical differences were found in the demographic and clinical data, and the main diagnostic laboratory parameters between patients with idiopathic EN versus those with secondary EN.

  Conclusion: Since EN can be isolated or the first manifestation of heterogeneous underlying pathologies, some of which can be severe and life-threatening, it is important to recognize it and carry out all the necessary etiological diagnostic investigations to understand its etiology and start the specific treatment.

What is Known:

• Erythema nodosum (EN) is the most frequent type of panniculitis in children.

• It has been associated with a wide spectrum of disorders, such as different types of infection, malignancies, chronic inflammations, and drugs.

What is New:

• No statistical differences can be found in clinical features as well as laboratory data, between patients with idiopathic EN versus those with secondary EN.

• A broad spectrum of investigations and a proper follow-up should be taken into account in order to prevent a delayed or missed secondary EN diagnosis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Availability of data and material

Materials described in the manuscript, including all relevant raw data, will be freely available to any researcher and reader.

Change history

Abbreviations

ANA:

Antinuclear antibodies

ANCA:

Anti-neutrophil cytoplasmic antibodies

ASCA:

Anti-Saccharomyces cerevisiae antibodies

ASO:

Anti-streptolysin O

CBC:

Complete blood cell count

CD:

Crohn’s disease 

CRP:

C-reactive protein

EBV:

Epstein-Barr virus

EN:

Erythema nodosum

ESR:

Erythrocyte sedimentation rate

IBD:

Inflammatory bowel disease

IQR:

Interquartile range

NSAIDs:

Nonsteroidal anti-inflammatories

PCR:

Polymerase chain reaction

pSS:

Pediatric Sjogren syndrome

QuantiFERON test:

Interferon-gamma release test 

SD:

Standard deviation

SS:

Sjogren syndrome 

References

  1. Garty BZ, Poznanski O (2014) Erythema nodosum in Israeli children. Isr Med Assoc J 2:145–146

    Google Scholar 

  2. Blake T, Manahan M, Rodins K (2014) Erythema nodosum – a review of an uncommon panniculitis. Dermatol Online J 20:22376

    Article  PubMed  Google Scholar 

  3. Calista D, Schianchi S, Morri M (2001) Erythema nodosum induced by kerion celsi of the scalp. Pediatr Dermatol 18:114–116. https://doi.org/10.1046/j.1525-1470.2001.018002114.x

    Article  CAS  PubMed  Google Scholar 

  4. Hassink RI, Pasquinelli-Egli CE, Jacomella V, Laux-End R, Bianchetti MG (1997) Conditions currently associated with erythema nodosum in Swiss children. Eur J Pediatr 156:851–853. https://doi.org/10.1007/s004310050728

    Article  CAS  PubMed  Google Scholar 

  5. Trapani S, Rubino C, Lodi L, Resti M, Indolfi G (2022) Erythema nodosum in children: a narrative review and a practical approach. Children 9:511. https://doi.org/10.3390/children9040511

    Article  PubMed  Google Scholar 

  6. Porges T, Shafat T, Sagy I et al (2018) Clinical, epidemiological, and etiological changes in erythema nodosum. Isr Med Assoc J 20:770–772

    PubMed  Google Scholar 

  7. Mana J, Marcoval J (2007) Erythema nodosum. Clin Dermat 25:288–294. https://doi.org/10.1016/j.clindermatol.2007.03.006

    Article  Google Scholar 

  8. Arnold J, Leung AKC, Lam JM (2020) Violaceous tender nodules symmetrically distributed over the pretibial area. Paediatr Child Health 25:201–202. https://doi.org/10.1093/pch/pxz030

    Article  PubMed  Google Scholar 

  9. Litwin L, Machura E (2014) The etiology and clinical manifestation of erythema nodosum in hospitalized children – analysis of 12 cases. Preliminary report Dev Period Med 18:506–512

    PubMed  Google Scholar 

  10. Polcari IC, Stein SL (2010) Panniculitis in childhood. Dermatol Ther 23:356–367. https://doi.org/10.1111/j.1529-8019.2010.01336.x

    Article  PubMed  Google Scholar 

  11. Labbe L, Perel Y, Maleville J, Taieb A (1996) Erythema nodosum in children: a study of 27 patients. Pediatr Dermatol 13:447–450. https://doi.org/10.1111/j.1525-1470.1996.tb00722.x

    Article  CAS  PubMed  Google Scholar 

  12. Picco P, Gattorno M, Vignola S et al (1999) Clinical and biological characteristics of immunopathological disease-related erythema nodosum in children. Scand J Rheumatol 28:27–32

    CAS  PubMed  Google Scholar 

  13. Bartyik K, Varkonyi A, Kirschner A, Endreffy E, Turi S, King E (2004) Erythema nodosum in association with celiac disease. Pediatr Dermatol 21:227–230. https://doi.org/10.1111/j.0736-8046.2004.21307.x

    Article  PubMed  Google Scholar 

  14. Leung AKC, Leong KF, Lam JM (2018) Erythema nodosum. World J Pediatr 14:548–554. https://doi.org/10.1007/s12519-018-0191-1

    Article  PubMed  Google Scholar 

  15. Kakourou T, Drosatou P, Psychou F, Aroni K, Nicolaidou P (2001) Erythema nodosum in children: a prospective study. J Am Acad Dermatol 44:17–21. https://doi.org/10.1067/mjd.2001.110877

    Article  CAS  PubMed  Google Scholar 

  16. Wallis P, Starr M, Phillips RJ (2016) An uncommon cause of erythema nodosum. J Paediatr Child Health 52:961–963. https://doi.org/10.1111/jpc.13267

    Article  PubMed  Google Scholar 

  17. Schwartz RA, Nervi SJ (2007) Erythema nodosum: a sign of systemic disease. Am Fam Physician 75:695–700

    PubMed  Google Scholar 

  18. Aydin-Teke T, Tanir G, Bayhan GI, Metin O, Oz N (2014) Erythema nodosum in children: evaluation of 39 patients. Turk J Pediatr 56:144–149

    PubMed  Google Scholar 

  19. Mert A, Kumbasar H, Ozaras R et al (2007) Erythema nodosum: an evaluation of 100 cases. Clin Exp Rheumatol 25:563–570

    CAS  PubMed  Google Scholar 

  20. Lins K, Drummond M, Velho PE (2019) Cutaneous manifestations of bartonellosis. An Bras Dermatol 94:594–602. https://doi.org/10.1016/j.abd.2019.09.024

    Article  PubMed  PubMed Central  Google Scholar 

  21. Carithers HA (1985) Cat-scratch disease. an overview based on a study of 1,200 patients. Am J Dis Child 139:1124–1133. https://doi.org/10.1001/archpedi.1985.02140130062031

    Article  CAS  PubMed  Google Scholar 

  22. Laborada J, Cohen PR (2021) Tuberculosis-associated erythema nodosum. Cureus 13:e20184. https://doi.org/10.7759/cureus.20184

  23. Mantadakis E, Arvanitidou V, Tsalkidis A, Thomaidis S, Chatzimichael A (2010) Erythema nodosum associated with Salmonella enteritidis. Hippokratia 14:51–53

    CAS  PubMed  PubMed Central  Google Scholar 

  24. Su CG, Judge TA, Lichtenstein GR (2002) Extraintestinal manifestations of inflammatory bowel disease. Gastroenterol Clin North Am 31:307–327. https://doi.org/10.1016/s0889-8553(01)00019-x

    Article  PubMed  Google Scholar 

  25. He S, Zhen X, Hu Y (2021) Juvenile primary Sjogren’s syndrome with cutaneous involvement. Clin Rheumatol 40:3687–3694. https://doi.org/10.1007/s10067-021-05656-0

    Article  PubMed  Google Scholar 

  26. Bonci A, Di Lernia V, Merli F, Lo Scocco G (2001) Erythema nodosum and Hodgkin’s disease. Clin Exp Dermatol 26:408–411. https://doi.org/10.1046/j.1365-2230.2001.00847.x

    Article  CAS  PubMed  Google Scholar 

  27. La Spina M, Russo G (2007) Presentation of childhood acute myeloid leukemia with erythema nodosum. J Clin Oncol 25:4011–4012. https://doi.org/10.1200/JCO.2007.12.0022

    Article  PubMed  Google Scholar 

  28. Lin JT, Chen PM, Huang DF, Kwang WK, Lo K, Wang WS (2004) Erythema nodosum associated with carcinoid tumour. Clin Exp Dermatol 29:426–427. https://doi.org/10.1111/j.1365-2230.2004.01544.x

    Article  PubMed  Google Scholar 

  29. Perez NB, Bernad B, Narváez J, Valverde J (2006) Erythema nodosum and lung cancer. Joint Bone Spine 73:336–337. https://doi.org/10.1016/j.jbspin.2005.10.009

    Article  PubMed  Google Scholar 

  30. Alvarez-Lario B, Piney E, Rodriguez-Valverde V, Pena-Sagredo JL, Peiro-Callizo E (1987) Erythema nodosum: study of 103 cases. Med Clin (Barc) 88:5–8

    CAS  PubMed  Google Scholar 

Download references

Author information

Author notes

  1. Sarah Abu-Rumeileh and Federica Barbati contributed equally to the manuscript.

Authors and Affiliations

  1. Postgraduate School of Pediatrics, University of Florence, Florence, Italy

    Sarah Abu-Rumeileh & Federica Barbati

  2. Pediatric Unit, Meyer Children’s Hospital, IRCCS, Florence, Italy

    Sarah Abu-Rumeileh, Federica Barbati, Giuseppe Indolfi & Sandra Trapani

  3. NEUROFARBA Department, University of Florence, Florence, Italy

    Giuseppe Indolfi

  4. Department of Health Sciences, University of Florence, Florence, Italy

    Sandra Trapani

Authors
  1. Sarah Abu-Rumeileh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Federica Barbati
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Giuseppe Indolfi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sandra Trapani
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

S.A.R and F.B made substantial contributions to conception and acquisition of data and wrote the main manuscript text. G.I. revised it critically for important intellectual content. S.T. made contribution on design and final approbation. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

Corresponding author

Correspondence to Federica Barbati.

Ethics declarations

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. As the study has an observational retrospective design, for this type of study, formal consent was not required.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Conflict of interest

The authors declare no competing interests.

Additional information

Communicated by Peter de Winter.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Abu-Rumeileh, S., Barbati, F., Indolfi, G. et al. Erythema nodosum in children: a cohort study from a tertiary pediatric hospital in Italy. Eur J Pediatr 182, 1803–1810 (2023). https://doi.org/10.1007/s00431-023-04872-x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00431-023-04872-x

Keywords

Search

Navigation