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CORRESPONDENCE
Year : 2020  |  Volume : 38  |  Issue : 4  |  Page : 246-247

A case of lung cancer presenting with erythema nodosum


1 Department of Dermatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
2 Department of Dermatology, Chang Gung Memorial Hospital; School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan

Date of Submission20-Jan-2020
Date of Decision10-Mar-2020
Date of Acceptance04-May-2020
Date of Web Publication16-Dec-2020

Correspondence Address:
Prof. Ching-Chi Chi
Department of Dermatology, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing Street, Guishan District, Taoyuan 33305
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ds.ds_22_20

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How to cite this article:
Fu Y, Chi CC. A case of lung cancer presenting with erythema nodosum. Dermatol Sin 2020;38:246-7

How to cite this URL:
Fu Y, Chi CC. A case of lung cancer presenting with erythema nodosum. Dermatol Sin [serial online] 2020 [cited 2021 Jan 22];38:246-7. Available from: https://www.dermsinica.org/text.asp?2020/38/4/246/303693



Dear Editor,

A 55-year-old woman presented to our dermatology clinic with multiple painful erythematous nodules on the legs for 4 months [Figure 1]a. A skin biopsy showed thickened vessels with mononuclear cells in the fat lobules surrounded by septal fibrosis [Figure 2]a and [Figure 2]b. A diagnosis of erythema nodosum (EN) was thus made.
Figure 1: Clinical presentations. (a) Multiple erythematous and tender nodules on the legs noted for 4–5 months. (b) A chest roentgenogram showing a tumor lesion in the right upper lobe with mild infiltration on the bilateral lower lung fields. (c) Computed tomography disclosed a 4.6-cm consolidated lesion in the right upper lobe

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Figure 2: Pathologic appearance of the lesion. (a) At scanning magnification, there is subcutaneous septal fibrosis and thickened vessels with inflammatory cells in fat lobules (H and E, ×40). (b) Histology magnification showing septal fibrosis and thickened vessels with mononuclear cells in the fat lobules (H and E, ×100)

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The patient had a history of chronic productive cough starting before the appearance of the skin lesions. A chest roentgenogram revealed a tumor in the right upper lobe [Figure 1]b. Computed tomography of the chest disclosed a 4.6-cm consolidation in the right upper lobe [Figure 1]c. Another tiny lung nodule was noted in the right middle lobe, which was considered intrapulmonary metastasis. No enlarged regional lymph nodes were noted. Computed tomography-guided core needle biopsy of the lung tumor showed adenocarcinoma, pT2aN0M0, Stage 1b. She received thoracoscopic right upper lobectomy and wedge resection of the right middle lobe with radical lymph node dissection. The tuberculosis–polymerase chain reaction test of the surgical specimens showed negative findings. She received four courses of chemotherapy with oral vinorelbine 100 mg twice per month and intravenous cisplatin 100 mg once per month. Meanwhile, the skin lesions on the bilateral legs gradually resolved. There were no signs of recurrence during a follow-up of 4 years.

EN is the most common form of panniculitis and was estimated to involve approximately 1–5 per 100,000 persons.[1] EN affects all ages, ethnic groups, and sexes, but more common in female, with a male-to-female ratio of 1:6 in adults and 1:1.2 in children.[2],[3] EN is characterized by tender erythematous nodules that are usually seen on the anterior aspect of both shins, but forearms, thighs, and trunk may also be affected. To date, the exact pathogenesis of EN remains to be elucidated but has been considered as a reaction to underlying disorders. Previous studies proposed a pathogenesis involving deposition of immune complexes in the septal venules of the subcutaneous fat, with the recruitment of leukocytes and the formation of granulomatous inflammation.[4]

Although the pathogenesis is unclear, previous studies have described the associations between EN and various conditions, such as medications, infections, systemic diseases, and malignancies.[1] Mert et al. have surveyed the possible causes of EN and concluded that the most common etiology of EN in developing countries was pulmonary tuberculosis.[5] On the other hand, EN may be a paraneoplastic cutaneous presentation, most often related to lymphoma or leukemia.[6] Other malignancies including colonic, cervical, and pancreatic cancers and carcinoid tumors have also been associated with EN.[7] The malignancies may appear before the onset of EN or may occur simultaneously.[8]

Treatments of EN should be directed at the associated underlying condition. However, more than 60% of EN occur with no underlying diseases. EN is generally a self-limited disease and may resolve spontaneously within a few weeks. Symptomatic treatments such as bed rest, leg elevation, and compressive bandage may be helpful. Medications for treating EN include aspirin, nonsteroidal anti-inflammatory drugs, and potassium iodide.

To date, there was only one previous case report of EN associated with lung cancer.[8] The previous report described a 43-year-old man with erythematous dermal and subcutaneous nodules on the shins that were refractory to treatments, including indomethacin and potassium iodide. He also suffered from nagging cough with blood-tinged sputum preceding the skin lesions by 1 month. After tumor removal and postoperative chemotherapy, the patient recovered well with EN resolved.

In conclusion, an underlying disorder should be sought in patients with EN. Although pulmonary tuberculosis is a frequent associated disorder, lung cancer is a potential comorbid disease that should be considered. Radiographic examination of the chest may be indicated when patients with EN present with respiratory symptoms, for example, chronic cough and blood-tinged sputum.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Schwartz RA, Nervi SJ. Erythema nodosum: A sign of systemic disease. Am Fam Physician 2007;75:695-700.  Back to cited text no. 1
    
2.
Kakourou T, Drosatou P, Psychou F, Aroni K, Nicolaidou P. Erythema nodosum in children: A prospective study. J Am Acad Dermatol 2001;44:17-21.  Back to cited text no. 2
    
3.
Requena L, Yus ES. Panniculitis. Part I. Mostly septal panniculitis. J Am Acad Dermatol 2001;45:163-83.  Back to cited text no. 3
    
4.
Kunz M, Beutel S, Bröcker E. Leucocyte activation in erythema nodosum. Clin Exp Dermatol 1999;24:396-401.  Back to cited text no. 4
    
5.
Mert A, Ozaras R, Tabak F, Ozturk R. Primary tuberculosis cases presenting with erythema nodosum. J Dermatol 2004;31:66-8.  Back to cited text no. 5
    
6.
Sullivan R, Clowers-Webb H, Davis MD. Erythema nodosum: A presenting sign of acute myelogenous leukemia. Cutis 2005;76:114-6.  Back to cited text no. 6
    
7.
Requena L, Yus ES. Erythema nodosum. Dermatol Clin 2008;26:425-38, v.  Back to cited text no. 7
    
8.
Perez NB, Bernad B, Narváez J, Valverde J. Erythema nodosum and lung cancer. Joint Bone Spine 2006;73:336-7.  Back to cited text no. 8
    


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  [Figure 1], [Figure 2]



 

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