TUBERCULOUS INFECTION WITH ERYTHEMA NODOSUM. 69

CLINICAL NOTES.

CASE OF TUBERCULOUS INFECTION WITH ERYTHEMANODOSUM.

HUGH GORDON, M.C., B.CH.CANTAB., M.R.C.P.LOXD.,

Dermatologist to the East London Hospital for Children.

A CHILD, aged 3 years, presented herself at the East London Hospitalon June 23rd, 1932, with a sore on the left side of the chin, a swollensubmaxillary gland, and '* lumps on the legs \ The history was thatthe sore had started as a pimple one week previously, and at the sametime the gland had become slightly swollen. During the course of theweek ' ' the head " of the pimple had come ofi, exposing the sore, whichhad been throughout quite painless. At the end of the week lumps hadappeared on the legs, which at first were slightly painful.

On examination there was a small shallow ulcer on the left side of thechin, half a centimetre in diameter. The base was clean and red in colour.The edges were not punched-out, and there was slight induration. Tliesubmaxillary gland on the left side was enlarged and tender, and theskin over it slightly reddened. On both legs below the knee she luulwhat appeared to be a typical erythema nodosum. with the exceptionthat the nodes were hardly tender at all. The child had no temperatureand felt perfectly well. Admission to hospital was refused by the parent.

A week later, June 30th, when seen again the legs were perfectly clear,the sore on the chin was smaller, but still definitely open, the submaxillarygland was larger, more tender, definitely fluctuant, and the skiii over itredder. The gland was aspirated, a little pus was drawn, wliich on exami-nation was found to contain tubercle bacilli in very large numbers. TheMantoux tests done during the next week with dilutions of 1 : 1,000,000down to ] : 1000 were all completely negative.

The child was put on general carbon arc baths three times a week,with cod-liver oil and malt internally.

During the next three weeks the sore on the lip gradually healed but

70 TUBERCULOUS INFECTION WITH ERYTHEMA NODOSUM.

never disappeared, there being definite staining present on glass pressure

and a little induration.The gland was aspirated weekly, but it became evident that it was

going to ulcerate through the skin and that a surgical procedure wouldbe necessary. Mr. Henry Wright excised the gland, which had completelybroken down, the wound healing after a certain amount of trouble.

The child was seen again on November 3rd. The place on the chinwas now a definite lupus nodule of the same size as the original lesion.There was a well-healed scar over the submaxillary gland. The Mantouxtest was fully positive in a dilution of 1 : 1,000,000.

The case is interesting in that it appears to be an example of a primarytuberculous inoculation in a child previously uninfected. It correspondsvery accurately to the picture described by Darier as a '̂ chancre tuber-culose primitif '̂(1). He mentions that the lesion " may be of varyingappearance accompanied by a large satellite gland, either an acneiformpustule or an erosion with an indurated base resembling a syphiliticchancre. It heals in several weeks, leaving a scar ". He mentions thatthe tuberculin reactions become positive at the end of twelve days or inseveral weeks.

In this case the lesion on the chin, when originally seen, resembled very

closely a syphilitic chancre.A second point of interest is the concurrent appearance of erythema

nodosum. According to the mother's history, the onset of the " lumpson the legs " occurred only a week after the spot on the chin was noticed,at the same time as the enlargement of the submaxillary gland. It ispossible, of course, that the original lesion on the chin may have beenpresent for some longer period without attracting attention. In any casethe erythema nodosum came and went without the child's Mantouxreactions becoming positive.

Unless one regards the appearance of the erythema nodosum as acoincidence, this case would appear to be an example of the conditionoccurring as a signal of a systemic invasion by the tubercle bacilli.

Unfortunately, owing to the child being operated on, etc., it is un-certain exactly when a condition of skin allergy as evidenced by Mantouxtests was established. When they were repeated three months after thechild's original visit they were strongly positive. By this time there hadappeared a lupus nodule on the site of the healed scar of the primarylesion.

PrTVHIASIS ROSEA. 71

It proved impossible to find any source of possible infection in thechild's household. There were no other children, and both parents wereapparently free from tuberculosis in any form.

REFERENCE.

(1) DkRiUH.—Precis de Dermatologie, 1928.

PITYRIASIS ROSEA AVITH LESIONS ON PALMS.

H. HALDIN-DAVIS. F R.C.P.

AFTER reading the report of a case of this disease with lesions of thepalms and soles published in the December number of the Journal byDr. F. C. Combes, I am tempted to send a brief note of a very similarcase which I saw at the Royal Free Hospital in October last. A girl,aged 16 years, presented herself with a profuse rash exhibiting the typicalcharacters of this disease, and there was no difficulty in making a diagnosis.A week later, however, the eruption had greatly increased all over thetrunk and had become far more squamous than usual, while upon thepalms there were numerous lesions exactly similar to those depicted inthe photograph illustrating Dr. Combes's case, and which were, as he,too, noted, quite indistinguishable from those of secondary syphilis. Soimpressed was I by these palmar lesions that I thought that I must havemade a mistake in the diagnosis, and the patient was consequently verycarefully examined for other signs of syphilis, but none could be found.The Wassermann reaction was negative ; in her case there were nosimilar lesions on the soles, and the whole eruption cleared up veryquickly with no treatment except the application of a little zinc cream.This was the first case of the sort I ever remember to have seen, and itmade a great impression on me, consequently I was very interested toread of Dr. Combes's parallel case.