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Ju, Kim, and Choi: A Case of Erythema Nodosum Associated with Mycoplasma pneumoniae Infection: Pathologic Findings and a Presumed Pathogenesis
Case Report

Pediatr Infect Vaccine 2016;23(1):67-71.

Published online: 21 January 2016

DOI: https://doi.org/10.14776/piv.2016.23.1.67

A Case of Erythema Nodosum Associated with Mycoplasma pneumoniae Infection: Pathologic Findings and a Presumed Pathogenesis

Hee Young Ju1, Gou Young Kim2, Sun Hee Choi1,

1Department of Pediatrics, Kyung Hee University School of Medicine, Seoul, Korea

2Department of Pathology, Kyung Hee University School of Medicine, Seoul, Korea

Correspondence: Sun Hee Choi Department of Pediatrics, Kyung Hee University School of Medicine. Seoul, Korea Tel: +82-2-440-6278, Fax: +82-2-440-6295 E-mail: chsh0414@Khu.ac.kr

Received 10 August 20152 October 2015       Accepted 6 October 2015

Copyright © 2016 The Korean Society of Pediatric Infectious Diseases

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Erythema nodosum (EN) is a painful skin disease characterized by erythematous tender nodules located predominantly over the extensor aspects of the legs. Various etiological factors, including infection, drug administration, and systemic illness have been implicated as causes of EN. Mycoplasma pneumoniae is one of rare infectious agents to cause EN in children. We report a case of a 7-year-old boy with context of respiratory illness and skin lesions with arthralgia. From stepwise approaches, IgM antibody against M. pneumoniae was positive with titers of 12.18, consistent with respiratory infection of M. pneumoniae and histopathology showed findings of septal and lobular inflammation without vasculitis consistent with EN. In addition, we reviewed the pathogenesis of this disease based on our case and the previous reports.

Keywords: Erythema nodosum, Mycoplasma pneumoniae, Type IV hypersensitivity, Pathogenesis

REFERENCES

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Fig. 1.
Scattered erythematous subcutaneous nodules located on pretibial surface of lower extremities.
piv-23-67f1.tif
Fig. 2.
There is septal (thick arrow) and lobular (thin arrow) inflammation composed of lymphocytes mixed with histiocytes. (A, H&E stain, X 40). There is a non-caseating small granuloma (circle) composed of ephithelioid histiocytes and surrounded by lymphocytes at septa of adipose tissue. No vasculitis is observed. (B, H&E stain, X 200).
piv-23-67f2.tif
Table 1.
Summary of Mycoplasma pneumoniae Induced EN Cases in Enalish Literature;
Patient age/sex Period from prodromal symptoms to symptom onset & Prodromal symptoms Clinical feature Rash location Rash duration Laboratory test Leukocyte count (/mm3) ESR (mm/hour) Orher findings Diagnostic method for Mycoplasma/ Biopsy for EN Reference
9.2 yr/female 5-15 days prodromal Fever Lower legs and forearms 10 days: WBC 9,800 (neutrophil 54%) ESR 84 Serology/(-) 3)
13.6 yr/female Fever and cough 5-15 days prodromal Arthralgia Lower legs 10 days WBC 7,200(neutrophi| 67.5%) ESR 113 Serology/(-)  
7 yr/female 5-15 days prodromal Lower legs and thighs ‘3 dam WBC 7,400(neutrophi| 40%) FSR 38 Serology/(-)  
8 yr/female EN, around 10 days, accompanied with EM, HSP Bilateral lower legs 9 days WBC 8,440 Proteinuria Serology/(-) 5)
10yr Co-infection with Streptococcus Bilateral lower legs NR WBC 11,000, ESR 80 Serology/NR 6)
8yr NR Bilateral lower legs NR WBC 11,000, ESR 37 Serology/NR  
10yr NR Bilateral lower legs NR WBC 11,000, ESR 45 Serology/NR  
7 yr/female Fever for 10 days with nodule and main in the lower limbs Bilateral lower legs and arm: 31 days WBC 10,500, ESR 120 Proteinuria Serology/(–) 7)
9 yr 1 month/ female Fever and cough for 5 days, 15 days interval Symmetric tibia 10 days WBC 14,300 (neutrophil 75%), ESR 45 Pneumonia: rale sound on lung field Serology/(-)  

Abbreviations: CRP, C-reactive protein, EM, erythema multiforme, EN, erythema nodosum, ESR, erythrocyte sedimentation rate, HSP henoch-schonlein purpura, NR, not reported.

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