33例脂膜炎与结核感染相关性分析

 目的 了解不同类型的脂膜炎患者与结核感染的相关性。方法 纳入2019年1月—2021年12月就诊于常德市第一人民医院33例脂膜炎患者的临床资料，对其临床特征、病理特征、与结核感染的相关性、治疗情况及随访情况进行分析。结果 ①33例脂膜炎患者中,结节性红斑24例，硬红斑9例，男女比例为1 ∶ 4.5，平均年龄46岁，平均病程10个月。②临床发病部位集中在四肢，均伴有疼痛。30例（90.91%)表现为红斑、结节、肿胀，其中1例硬红斑（3.03%）出现溃疡。6例(18.18%)出现发热、咳嗽、盗汗。2例硬红斑患者同时伴有或先后出现丘疹性坏死性结核疹，2例结节性红斑患者伴有全身多关节疼痛。③22例（66.67%,包括9例硬红斑、13例结节性红斑)伴结核分支杆菌潜伏感染（LTBI）。硬红斑患者结核感染阳性率高于结节性红斑患者（P＝0.020）。④皮损组织病理表现为间隔性脂膜炎11例、小叶性脂膜炎3例、混合性脂膜炎19例。与结核感染相关的22例脂膜炎患者病理下多可见上皮细胞肉芽肿、多核巨细胞以及干酪样坏死，其余11例均可见真皮层血管周围及脂肪间隔淋巴细胞浸润，且均未见上皮样肉芽肿及多核巨细胞。33例患者抗酸染色、PAS染色、直接免疫荧光均未见阳性表现。⑤22例与结核感染相关患者中，接受抗结核治疗15例，治愈率为68.18%，拒绝接受抗结核治疗患者7例，治愈率为14.29%。11例结核感染不相关患者采用免疫调节联合治疗，治愈率为100%。所有患者均未出现严重药物不良反应。结论 硬红斑患者的结核感染阳性率比结节性红斑患者高。在结核感染相关的脂膜炎患者中，接受抗结核治疗者治愈率比免疫调节联合治疗者高；对于未发现结核感染证据的结节性红斑，免疫调节治疗可能有效。结节性红斑患者的发病原因可能与结核感染相关。在结核高发地区，结节性红斑患者完善相关筛查极其重要。     

温阳法治疗硬红斑/结节性血管炎临床分析

正硬红斑(erythema induratum)分为2型,一种为Bazin型,属血源性皮肤结核病,另一种为Whitfield,是一种血管炎,即结节性血管炎。硬红斑与结节性血管炎临床与病理相似,是否应各为独立疾病尚有不同看法,Lever等认为结节性血管炎仅是硬红斑的早期或轻型~([1])。临床上两者均好发于小腿屈面,常对称分布。基本损害为豌豆至蚕豆大的皮下硬结,逐渐增大并与皮肤粘连,呈暗红色或紫红色,结节可渐软化破溃,形成深在性不规则坑穴样伴以陡峭或潜行性溃疡,分泌物稀薄淡黄色或带有干酪样小块脓液。溃疡经久不愈~([2])。     

Bazin 硬红斑一例

Bazin 硬红斑误诊为丹毒1例周李燕 李超江阴市中医院 无锡 214400 Bazin硬红斑 (erythema induratum)又名硬结性皮肤结核(tuberculosis cutis indurativa),是一种深部血源性皮肤结核。最近我们在临床诊治中有1例被误诊为丹毒的硬红斑患者,现报道如下。患者男,58岁,左下肢肿痛反复发作3月余,2009年5月患者因左下肢肿痛收住外科,予以美洛西林,异帕米星抗感染治疗后肿痛明显消退.8月18日左右,又现左下肢肿痛,局部皮温高,来我科以“丹毒”收住我科,先后予以头孢西丁、阿奇霉素、阿莫西林克拉维酸甲、环丙沙星抗感染2周后,皮疹未见明显好转,疼痛有所加重。体格检查：生命体征正常,内科系统无异常,皮肤科检查：左下肢踝关节内侧一5×10c㎡大小边界不清的暗红色硬化斑,局部皮温偏高,硬斑周围至整个脚背满布褐色色素沉着斑。既往有肺结核史十余年,追问病史,患者至今仍间断服用利福平消炎,未予正规抗痨治疗。07年因摔伤行股骨粗隆间骨折固定术,09年2月行钢板摘除术。实验室检查：血尿常规,肝功生化基本正常,PPD实验阳性,病损皮肤病理示：表皮无异常,真皮内血管及胶原纤维增生,血管汗腺周围嗜酸性粒细胞,淋巴细胞,浆细胞浸润,局部见灶性坏死,周围多核巨细胞及类上皮细胞。经异烟肼、利福平、乙胺丁醇口服半个月,患者局部肿痛明显好转,局部皮温不高,少许压痛,复查肝功能正常,继续服用上述三种抗痨药物,一个月后随访,右下肢红肿大部分消退,患处轻微压痛,局部皮肤较前变软,色素沉着较前变淡,继续上述治疗三个月,病情恢复中。讨论 :硬红斑分为Bazin硬红斑和Whitfield硬红斑。是一种发生于下肢的慢性、复发性、结节性和溃疡性皮肤病,皮损多对称分布,可软化破溃,形成溃疡,愈后留有萎缩性疤痕,色素沉着,自觉疼痛和压痛。患者通常伴有肺结核、淋巴结核或其他远隔部位结核病灶,结核菌素实验阳性〔1〕。病理显示为T细胞介导的超敏反应。Bazin硬红斑是1861年由Bazin首先描述,其和结核的关系一直存在争论,焦点问题在于组织中抗酸染色以及培养中查不到结核菌〔2,3〕。李宝强等在硬红斑皮损中结核杆菌DNA的检测中推测硬红斑不是由完整的结核杆菌在局部沉积或感染所引起,而可能是由其它原因或其它部位的结核杆菌产生的蛋白或碎片作为抗原引起的变态反应所引起〔4〕。大多数学者仍主张首先抗痨治疗,异烟肼治疗至少6-8个月,如果无效可考虑更改治疗方案,临床观察早期并用小剂量泼尼松治疗,皮损消退快且局部组织损伤少。本例患者三联疗法三个月后明显好转。 误诊原因：该患者临床上以疼痛性结节为主要表现,抗炎治疗能缓解,且患者长期间断服用利福平,皮疹缺乏特征性,常与结节性红斑、丹毒、结节性血管炎相混淆, 缺乏对硬红斑的全面认识,忽略了结核方面的检查和组织病理,从而拖延病程。     

结核相关结节性红斑的研究进展

结节性红斑(erythema nodosum,EN)是一种常见的间隔性脂膜炎,以红斑、炎症性皮下结节为主要表现。其病因复杂,目前认为部分EN与结核菌感染关系密切。结核相关EN好发于女性及青少年,最常见的结核病类型是原发型结核和淋巴结结核,但大多数患者缺乏相应结核病表现。其发病机制认为与免疫复合物介导的以及细胞介导的免疫机制有关。EN主要根据皮损病理诊断确诊,其组织学表现为不伴血管炎的间隔性脂膜炎,多有间隔增厚,伴各种炎性细胞浸润。当怀疑结核菌感染时,则需完善结核菌素试验、结核抗体、胸片、痰培养等相关检查以明确诊断。认为即使缺乏明确的结核感染证据,对于结核菌素皮肤试验强阳性的患者,尤其是在结核流行病区,应该进行抗痨治疗。     

结节性血管炎的研究进展

结节性血管炎和硬红斑在临床和病理上相似,是否和硬红斑为同一疾病尚无定论,目前认为,结节性血管炎找到结核杆菌感染的证据即为硬红斑.临床上中年女性下肢尤其是小腿后侧的疼痛性复发性紫红色结节或斑块,应高度怀疑本病.确切病因不明,曾认为是结核感染引起,目前推测可能与结核、衣原体、链球菌等感染、自身免疫性疾病、肿瘤等都有一定联系.多数患者的组织病理显示为小叶性脂膜炎.治疗上应尽可能找出潜在的病因,治疗的药物有碘化钾、糖皮质激素、非甾体抗炎药等.     

婴儿结节性脂膜炎1例

报道1例婴儿结节性脂膜炎。患儿男,6个月2天,发热4天,躯干、四肢出现红斑、结节2天。皮肤专科检查:背部、四肢散在直径1～2 cm的水肿性红斑,类圆形,部分中央颜色较淡,可见假性水疱,红斑基底可触及质硬结节,触痛明显。皮损组织病理:真皮血管内可见灶性淋巴细胞、中性粒细胞浸润,脂肪小叶内可见弥漫成片的中性粒细胞浸润,并见脂肪坏死。免疫组化未见T淋巴细胞、B淋巴细胞免疫表型表达。诊断:结节性脂膜炎。入院后予大剂量激素、抗感染等治疗,患儿病情逐渐好转,出院后随访4年,未见复发。     

Bazin硬红斑中T-淋巴细胞对结核菌纯化蛋白衍生物高应答反应:两例报告及治疗

Bazin硬红斑是一种结节和溃疡性慢性疾病,好发于女性腿部,可伴有结核杆菌的慢性感染。然而,该病的真正起因仍是一种推测且有疑问。本文报告两例Bazin硬红斑,并进行临床研究及其外周血T淋巴细胞对结核菌纯蛋白衍生物(PPD)的体外反应。 例1.女性,58岁,双小腿出现蓝红色斑块样中心有溃疡结节21年,无结核病史。病人用三联抗结核治疗(利福平900mg/d,异     

丹参酮胶囊并光量子疗法治疗结节性红斑的临床及免疫学研究

结节性红斑是一种发生在真皮和脂肪的血管炎及脂膜炎，可能与感染诱发的免疫功能紊乱有关。近年来，我们采用丹参酮胶囊并光量子疗法联合治疗结节性红斑40例，临床近、远期疗效满意。为探讨该疗法的作用机制，我们分别于治疗前、后监测观察了患者血液中免疫复合物的变化，现报道如下。     

近25年结节性红斑患者中结核感染特点的Meta分析

目的：明确1993-2018年结节性红斑(EN)患者中结核(TB)感染特点。方法：2位研究者独立检索1993年1月至2018年9月PubMed、Embase、MEDLINE、CNKI、CBM、万方数据库筛选出符合纳入标准的文献，采用STATA 12.0软件通过Meta分析方法进行单个率的合并分析。结果：共纳入27篇文献，包括国内11篇（1019例患者，其中结核性结节性红斑患者277例，感染率25.4%），国外16篇（995例，其中结核性结节性红斑患者52例，感染率6%）。国内亚组分析显示东部、中部及西部地区EN患者中结核感染率分别为16.0%、27.9%和32.5%，Meta回归显示地区因素而非年份因素可解释异质性来源(P=0.02)。结节性红斑患者结核病灶为肺结核、淋巴结核、其他类型结核（如：结核性胸膜炎、卵巢结核等）、仅PPD强阳性，分别占44.4%、11.1%、7.1%及38.2%。结论：大多数EN患者没有明显的结核症状，因此应尽量寻找潜在的结核病感染病灶。     

结节性红斑的病因学研究进展

结节性红斑是一种脂膜炎,常发生于双侧胫前,以红斑、痛性皮下结节为主要表现.青年女性好发.组织学表现为间隔性脂膜炎,伴多种炎症细胞浸润.确切的发病机制尚不明确,目前认为可能是一种迟发超敏反应,也有学者认为,是免疫复合物沉积在脂肪间隔的小静脉所致,引起嗜中性脂膜炎.病因复杂,与感染、系统性疾病、药物、激素水平、恶性肿瘤等因素相关.由于地区差异,病因可能有所不同.     

Erythema induratum of bazin

Erythema induratum of Bazin is a chronic, nodular eruption that usually occurs on the lower legs of young women. It has been regarded as a manifestation of tuberculin hypersensitivity, a type of tuberculid occurring on the legs, whereas nodular vasculitis represents the nontuberculous counterpart. The number of reports of erythema induratum of Bazin is decreasing in most developed countries in accordance with the decreased incidence of tuberculosis. The etiopathogenesis of erythema induratum of Bazin and its relation to tuberculosis are still controversial, because mycobacteria cannot be cultured from the skin lesions. Most authors currently consider erythema induratum of Bazin (nodular vasculitis) a multifactorial disorder with many different causes, tuberculosis being one of them.     

Erythema induratum of Bazin and Poncet''s disease – successful treatment with antitubercular drugs

Erythema induratum of Bazin (EIB) is considered a tuberculide reaction and consists of recurrent painful nodules predominantly on the calves. Clinically it has common features with diseases like nodular vasculitis, perniosis, polyarteritis nodosa and erythema nodosum. Poncet's disease is a reactive arthritis that may accompany tuberculosis. We report a case of a young woman in which the simultaneous occurrence of erythema induratum of Bazin and Poncet's disease led to a clinical picture very similar to Löfgren's syndrome. The final diagnosis was obtained by polymerase chain reaction detection of mycobacterial DNA in a skin biopsy. A systemic therapy with tuberculostatic drugs led to the disappearance of symptoms. The presented case shows the usefulness of polymerase chain reaction diagnostics in EIB patients without other clinical signs of tuberculosis and a confusing combination of symptoms, and further confirms the presence of mycobacterial DNA in EIB lesions.     

Erythema induratum Bazin nach Lungentuberkulose

Summary: Mycobacterium tuberculosis can be directly demonstrated in lesions of cutaneous tuberculosis, but mostly could not be demonstrated in Tuberculids. These include erythema induratum of Bazin, papulonecrotic tuberculid as well as lichen scorphulosorum. Tuberculids result from the hematogenous spread of Mycobacteria tuberculosis in a person with a high degree of immunity. We report on a 63‐year‐old woman with erythema induratum of Bazin and pulmonary tuberculosis in medical history, with hightened tuberculin sensitivity and negative bacterial cultures. Polymerase chain reaction (PCR) could not detect Mycobacterium tuberculosis‐specific DNA. After eight weeks only, the patient responded well to a course of antituberculosis therapy (isoniazid, ethambutol, rifampicin and pyracinamide) with marked resolution of the lesions. The tuberculous origin of erythema induratum of Bazin is still controversal, since mycobacteria cannot be cultured from skin lesions. Since the availability of PCR‐diagnostic, in some cases, but not in our patient, PCR was positive für Mycobacterium tuberculosis‐specific DNA. The good response to antituberculosis therapy is a further argument for the association of erythema induratum of Bazin and Mycobacterium tuberculosis     

Panniculitis in tuberculosis: a clinicopathologic study of nodular panniculitis associated with tuberculosis

Background Certain types of panniculitis, erythema induratum of Bazin and erythema nodosum, have been well documented as tuberculids. Many histopathologic diagnoses of panniculitis have been reported in tuberculosis patients. This study investigates the correlation between underlying tuberculosis and clinicopathologic findings of panniculitis.
Methods We retrospectively reviewed the clinical files of histologic-proven panniculitis cases at the Dermatologic Clinic, Siriraj Hospital from January 1992 to December 1995; only cases with active tuberculous foci were analyzed.
Results The incidence of panniculitis caused by tuberculosis was 8.2%. The ratio of men to women was 1 : 1. The mean age of onset was 35.3 years. The average duration of the nodules was 35.5 days. There was a history of contact tuberculosis in 16.6%. Constitutional symptoms and a strongly positive purified protein derivative (PPD) reaction were found in 66.6%. Chest roentgenograms were abnormal in 83.3%. The erythrocyte sedimentation rate was elevated in all tested cases. The histopathologic diagnoses were nodular vasculitis (33.3%), erythema nodosum (50%), and cutaneous periarteritis nodosa (16.4%). The panniculitis lesion responded to standard antituberculous regimens in 4.6 weeks, on average, with residual hyperpigmentation.
Conclusions In panniculitis patients, clues for the investigation of tuberculosis included constitutional symptoms, elevated erythrocyte sedimentation rate, and abnormal chest roentgenograms. Histopathologic changes of panniculitis did not seem to correlate with underlying tuberculosis. The clinician should be aware of the tuberculosis, however, and should carefully search for active foci in all panniculitis patients.     

ERYTHEMA INDURATUM OE BAZIN

Background. There has been a long controversy about the tuberculous cause of erythema induratum, a chronic form of nodular vasculitis. Method. We investigated clinical, histopathologic, and immunohistochemical features of patients with erythema induratum who showed positive tuberculin hypersensitivity reactions or had associated active tuberculosis. Results. The ages of the 32 patients (M 7: W 25) ranged from 13 to 66 years (mean 36.6 years). All patients displayed recurrent crops of tender, painful, violaceous nodules or plaques. Most lesions presented on the legs, but they also occurred on thighs, feet, buttocks, and forearms. The skin lesions evolved for several weeks and healed with scarring and residual pigmentation. Twenty-two patients were treated with isoniazid alone and the remaining 10 patients received combinations of antituberculous drugs. Relapses were encountered in four patients who received isoniazid alone or stopped the medication against medical advice. In most biopsies, histologic examination revealed lobular or septolobular panniculitis with varying combinations of granulomatous inflammation, primary vasculitis, and necrosis. Immunohistochemical labeling revealed a preponderance of T lymphocytes, monocyte-macrophages, and Langerhans' cells, indicative of a type IV hypersensitivity reaction. Conclusion. Erythema induratum of Bazin has distinct clinical, histopathologic, and immunohistochemical features. Erythema induratum of Bazin should be considered as a separate entity of nodular vasculitis caused by latent foci of tuberculous infection.     

Nodular tuberculid: a report of four patients

The tuberculids are hypersensitivity reactions to Mycobacterium tuberculosis (MTB) and include papulonecrotic tuberculid (PNT), lichen scrofulosorum, erythema induratum of Bazin (EIB), and phlebitic tuberculid. Papulonecrotic tuberculid displays papulonecrotic lesions mostly on the extensor surfaces of the limbs. Histopathology shows necrosis, granulomatous inflammation (GI), and occasionally vasculitis, usually in the superficial dermis. Erythema induratum of Bazin shows nodulo-ulcerative lesions on the posterior aspect of the legs. Histopathology reveals a septolobular panniculitis, necrosis, GI, and vasculitis. The Mantoux test is strongly positive and associated tuberculosis (TB) may be present in both conditions. MTB cannot be demonstrated with a Ziehl-Neelsen (ZN) stain or cultured. The polymerase chain reaction has demonstrated MTB DNA in PNT (50%) and EIB (25%). The tuberculids respond to full anti-TB treatment. We document four patients with nodules on the legs in whom the pathologic changes were situated in the deep dermis and adjacent subcutaneous fat. Nodular tuberculid (NT) is regarded as a suitable term for these lesions. All patients were female. Their ages were 19 months, 12 years, 17 years, and 5 years. All patients presented with nodules on the limbs. These nodules were approximately 1 cm in diameter, dull red or bluish-red, and nontender. Ulceration was not present. The number of nodules varied from a few to many. The Mantoux test was strongly positive in all the patients. Associated pulmonary TB was present in two patients. Histopathology showed GI (n = 4), vasculitis (n = 2), and coagulative necrosis (n = 2). A ZN stain was negative in each case. All patients received anti-TB treatment for 6 months [rifampicin (n = 4), isoniazid (n = 4), pyrazinamide (n = 4), and ethambutol (n = 2)]. At 12 months follow-up, skin and pulmonary lesions had resolved in all. Nodular tuberculid should be distinguished from arthropod bites and papular urticaria, dermal erythema multiforme, evolving vasculitis, evolving folliculitis, and erythema nodosum. Histopathologically NT should be distinguished from other causes of granulomatous vasculitis and GI with or without necrosis. In children with nodules on the limbs unresponsive to routine treatment, skin biopsy should be done to exclude NT. Nodular tuberculid represents a hybrid between PNT and EIB with characteristic clinicopathologic features and should be included in the classification of cutaneous TB.     

Erythema nodosum and erythema induratum (nodular vasculitis): diagnosis and management

Erythema nodosum is the most common type of panniculitis; it may be due to a variety of underlying infectious or otherwise antigenic stimuli. The pathogenesis remains to be elucidated, but both neutrophilic inflammation and granulomatous inflammation are implicated. Beyond treating underlying triggers, therapeutic options consist mainly of nonsteroidal anti‐inflammatory drugs, symptomatic care, potassium iodide, and colchicine. Erythema induratum (nodular vasculitis) is a related but distinctly different clinicopathologic reaction pattern of the subcutaneous fat. It is classically caused by an antigenic stimulus from Mycobacterium tuberculosis but may be associated with several other underlying disorders. After appropriate antimicrobial treatment in tuberculous cases, therapy for erythema induratum is similar to options for erythema nodosum.     

Erythema induratum of Bazin in an infant after Bacille Calmette-Guerin vaccination

We report the first case of erythema induratum of Bazin (EIB) after Bacille Calmette-Guerin (BCG) vaccination in an infant. The patient developed recurrent multiple erythematous and subcutaneous nodules on his legs 2 months after a BCG vaccination. He had no other symptoms or family history of tuberculosis (TB). Histopathological findings revealed a granulomatous lobular panniculitis. EIB often appears as a chronic, nodular eruptions that frequently occur on the lower legs of females with tuberculin hypersensitivity. To date, only a few cases of infants with EIB have been reported. There have been no clinical reports of EIB after BCG vaccination. Our case suggests that Mycobacterium bovis in the BCG vaccination may have caused EIB.