Articular manifestations of erythema nodosum.

Erythema nodosum was first distinguished from other forms of erythema by Willan (1808), and Hebra (1860) amplified Willan's account of the condition as follows: " . . . tumours of a pale red colour, raised above the level of the skin, and either semi-globular or oval in form. These swellings are tender on pressure, and are observed chiefly on the lower limbs. In some cases, the outbreak of this form of erythema is preceded by slight febrile disturbance, and even by shivering. . . They have at first a pale rose red colour, with a slight tinge of yellow. Afterwards they become dark red, then livid; and when the red colour has faded, a yellowish coloration remains for a considerable time." Neither author mentioned arthritic manifestations, but Mackenzie (1886) reported a study of 108 cases of erythema nodosum in 34 of whom there were symptoms of joint involvement. Various authors have subsequently confirmed the association. Lofgren (1946) reviewed 178 cases oferythema nodosum; 57 per cent. of his patients complained of painful joints at the outset, and 27 per cent. had actual joint swelling. In this series L6fgren classified the aetiology as tuberculous in 104 patients and as streptococcal in thirty. In a subsequent investigation (LUfgren, 1953a), he studied 212 patients with bilateral hilar gland enlargement associated with a negative or weakly positive reaction to tuberculin; 113 of them had erythema nodosum as a presenting symptom, 101 with arthralgia and 78 with actual joint swelling. James (1959) analysed 200 patients with histological evidence of sarcoidosis in the form of non-caseating giant-cell systems; 62 of them (31 per cent.) had erythema nodosum and of these forty (64 per cent.) suffered from polyarthralgia. These patients had no joint effusions and the arthralgia settled without sequel. All but three had bilateral enlargement of the hilar glands.