Erythema Nodosum w/out the red color ???

[2isenough]

11 yr. old son has had (what 3 doctors) have diagnosed as Erythema Nodosum, but without the change in color (no redness -- rarely a faint pink on the thigh nodules) for the past two years.  Three positive strep throat cultures from 1/2006 to 2/2007.  No positive strep test since 2/2007.  His ASO titer has been between 800 and 1010 range for the last 2 years (last week's 1000).  He has taken a multitude of oral antibiotics --Amoxil 875 Mg 2x day for 14 days, to straight penicillin, Rifampin 300 Mg 2x day for 10 days, Clindamycin.  Nothing seems to rid him of these nodules or lower his ASO titer.   Overall crummy feeling most of the time.  Headaches, leg aches, joint aches, back ache, neck ache.  Any suggestions?

[BhumikaMD]

Hi,

You should also consult a rheumatologist or bone and joint specailist since other causes of these symptoms need to be ruled out.

Rheumatic disease needs to be ruled out from the symptoms you describe, and it also will cause high ASO titres.

Till then let him take OTC pain relief medications for the pain.

Do let us know what the specialist advises.

Hope this helps.

Regards.

[2isenough]

Dear BhumikaMD,

Thank you for your reply!  10/2007 my son was seen by an infectious disease doctor at a local children's hospital that ranked #28 in the nation (thinking that would be the place we would finally get our answers).  I was told that we may not ever know what's causing this and he will just have to live with it.  To me, that's not satisfactory, but I wonder if this is the truth and I should come to accept it?  To add to the list of aches, tiredness and overall crummy feeling, I should also mention he does have frequent stomach aches, with occasional loose bowel movements.   I have recently changed pediatricians (ours wanted to place my son on a 24 month regimen of Penicillin – even though rapid and cultured throat strep tests are negative).  Below is a rough time line of illnesses with laboratory results.  I would appreciate any and all suggestions of possible avenues I may research!  Respectfully!

* born with tear duct infection

* 9 ear infections in first year

* at 5 months of age, tested negative for Cystic Fibrosis

* 7/2002 Transient Synovitis of the hip – treated with Rx with frequent observation

* 11/2002 tonsillectomy and adenoidectomy (ENT stated these were some of the worse pus filled that he has ever seen)

* 1/2006 my (at that time 9 yr. old son) developed nodules on both legs.  They were slightly pink, warm to touch, were not moveable under the skin, at times, they were slightly painful to touch.  This was accompanied with aches in the legs with sore knee joints and ankle joints, tiredness and an overall crummy feeling.  No fever was detected.  He was immediately seen by his pediatrician, who seemed perplexed (negative strep culture) and after consulting another collogue he diagnosed as Erythema Nodosum most likely from a case of strep throat.  Doc. informed that nodules should diminish in a few weeks to a month.  Sent for blood lab work which showed:

SED rate 5
WBC 4.9
RBC 4.43
Hemoglobin 13.6
Hematocrit 38.1
MCV 85.9
MCH 30.6
MCHC 35.6
RDW 12.4
Platelet count 406 (high)
Absolute Neutrophils 2965
Absolute Lymphocytes 1411 (low)
Absolute Monocytes 456
Absolute Eosinophils 49
Absolute Basophils 20
Neutrophils 60.5
Lymphocytes 28.8
Monocytes 9.3
Eosinophils 1.0
Basophils 0.4
Anti-Streptolysin O 1010 (high)

Rx – Amoxil 500 Mg BID x 10 days and Advil PRN

* 20 days later – Positive strep test with same nodules on legs.
Rx – Amoxil 500 Mg BID x 10 days

* Nodules, although seemed to be getting smaller, persisted through spring until disappearing.

* 10/2006 Nodules return on both legs.  Warm to touch, sore to touch, no fever.  Negative strep test.   Rx – Amoxil 500 Mg BID x 10 days.
Lab test showed:

Comprehensive Metabolic Panel w/EGFR Glucose 103 (high)
UREA Nitrogen (BUN) 9
Creatinine 0.5
BUN/Creatinine Ration 18
Sodium 139
Potassium 4.6
Chloride 104
Carbon Dioxide 22
Calcium 9.4
Protein, Total 7.4
Albumin 4.5
Globulin 2.9
Albumin/Globulin ration 1.6
Bilirubin, total 0.5
Alkaline Phosphatase 197
AST 29
ALT 20
SED rate 4
WBC 7.6
RBC 4.19
Hemoglobin 12.6
Hematocrit 35.6
MCV 85.0
MCH 30.1
MCHC 35.4
RDW 12.4
Platelet Count 388
Absolute Neutrophils 4203
Absolute Lymphocytes 2554
Absolute Monocytes 714
Absolute Eosinophils 76
Absolute Basophils 53
Neutrophils 55.3
Lymphocytes 33.6
Monocytes 9.4
Eosinophils 1.0
Basophils 0.7
Anti-Streptolysin O 972 (high)
C - reactive protein <0.10
Tuberculosis skin test -- negative


* 11/2006 Nodules continue with increase in number of nodules.  Rx given (unable to read doc. notes)

* 1/2007 persistent headaches (waking with in the morning and going to bed with one) – MRI negative

* 2/2007 Nodules never went away from last occurrence.  Positive strep test.  Rx – Amoxil 500 Mg BID x 10 days

* 2/2007 Nodules continue.  Negative strep test.  Rx – Penicillin VK 500Mg BID x 10 days

* 3/2007 Nodules continue.  Positive strep test.  Rx – Amoxil 500 Mg BID x 10 days

* No sign of nodules from 5/2007 to 9/2007

* 9/2007 Nodules appear again on lower legs.  Negative strep test.  Rx – Amoxil 500 Mg BID x 10 days

* 10/2007 Nodules continue; however, they are also on upper thighs – very painful to touch.  Pediatrician referred us to see an infectious disease doc. that also diagnosed nodules as Erythema Nodosum and said that we may never know why patient continues to have Erythema Nodosum and “may just have to live with it”. Lab test showed:

Electrolytes (NA) 136 (K) 3.5 (CI) 100 (CO2) 26 (AGAP) 10
Glucose 109 (high)
BU 6
Creatinine 0.7
Total Protein 8.0
Alb 4.3
Enzymes (GGT) 50 – high (ALT) 44 (AST) 32 Angiotensin Conv 40
WBC 6.6
ABC 4.63
Hgb 13.7
Hct 38.4
MCV 82.9
MCH
29.6
MCHC 35.7
RDW 12.3
Platelet 397
MPV 9.4
ANC 4.08
Seg 62.0
Eos 0.8
Baso 0.5
Mono 11.4 (high)
Lymph 25.3
Sed Rate (ESR) 4
C - reactive protein 0.1
Urine – negative for protein, glucose, ketones, blood, bilirubin, nitrites, leukocyte est.
ASO titer 800 (high)

Rx – Rifampin 300Mg BID and AMOX CLAV 875 Mg BID x 14 days  

11/2007 Negative strep test. Nodules continue; however, they present no color. Negative strep test. Rx – Rifampin 300Mg BID and AMOX CLAV 875 Mg BID x 14 days  

* 12/2007 Negative strep test. Nodules continue on lower legs with no color.  Nodules have gone away on upper thighs.  Doc wanted to prescribe above meds.  I declined because of repeated negative strep test.

*1/2007 new doctor.  Negative strep test.  Nodules continue with new ones appearing.  Lab test show:

WBC 8.1
RBC 4.58
Hemoglobin 13.4
Hematocrit 39.0
MCV 85
MCH 29.2
MCHC 34.2
RDW 12.7
Platelets 392
Neutrophils 68 (high)
Lymphs 22 (low)
Monocytes 9
Eos 1
Basos 0
Neutrophils absolute 5.5
Lymphs absolute 1.8
Monocytes absolute 0.7
Eos absolute 0.1
Baso absolute 0.0
RA Latex Turbid. 7.8
Antinuclear Antibodies Direct 26
Sed rate 15
C reactive protein, quant 0.3
ASO titer 1000

No positive strep since 3/2007.  However, ASO titer has increased and Nodules are persistent and have not gone away in almost 5 complete months.  Overall continuous crummy feeling with tiredness and leg, knee joint, ankle joint, back, neck, stomach, and head aches (occasional loose bowel movements and nausea)

[BhumikaMD]

Hi,

Ask your doctor for blood tests including rheumatoid factor, and tets for systemic lupus erythematosus including anti double starnded DNA, ANA, p ANCA, c ANCA, anti- RO antibody, anti la antibody.

This should be combined with a excision biopsy of the skin nodule which should be sent for lab analysis.

Do let us know if your doctor agrees to get the tests done.

Regards.

[alex117]

Hi, This might be nothing but I think your son might have the same thing as my daughter.Some of your son's symptoms my daughter does not have like the nodule but the thing that stick with me is the strep. let me tell you my daughter's history and see what you think.
April 13, 2006 Strep throat-amoxocilin
April 19,2006 chg meds to erthromicin 60EES
April 25,2006 white blood count up to 23,000
April 28,2006 white blood count 10,000
April 29,2006 rash low grade fever for one wk

at this point the doc wants me to send her back to school with a fever-I refuse chg doc

May 4,2006 chest wall inflamed
may 11, 2006 Upper GI-sliding hiatial hernia, irratation in intestial track, swollen lymnods,

She was ill from April until Aug of that year.  She had stomach pains, chest pains, joint pains, muscle weakness, headaches, nose bleeds, rashes, neausea, and dizziness.  I am sure I didn't get all of them.

2nd illness- Sept till March same symptoms.

3rd illness- end of Nov till present.

She has seen cardiologist, rheaumotologist,gyno, 2 gastro,physcologist,endo, an internist,and allergist.  

The best guess I heard from all the docs was pryphria.  Which is a heriditary metoblic disease  that is triggered by medication.  But that test came back neg.

I do believe this is connected to the strep.  and I believe everytime she gets sick and is put on meds it retriggers the illness.

Does your son's symptoms come in cycles.  Do they last for months at a time?  When he has stomach pain have the determined if it is in the colon and intestine or is in the cavity of the stomach wall?  Do you live in a cold weather state?  

Well, let me know what you think.  I am starting with a new internist on Wed. (only bec the ped is having a baby) her and the ped talk in lenght about her symptoms.  They are very determined to figuire it out.  Thanks a lot, June

[BhumikaMD]

Hi,

How is your son doing now?

Do keep us posted if possible about the appointment with your doctor;s, his health and also if you have any doubts.

Regards.

[2isenough]

My son continues to be ill.  We had another negative strep test last week.  He has the worst sore throat and is so tired!  He has had new nodules come and go.  The most recent nodules are on his inner thighs and are very painful.  The redness is much worse with these, but the nodule isn’t as raised.  We have an appointment this week with a Rheumatologist at Scottish Rite Hospital in Dallas, TX.  Hopefully, we will get some answers!!

I'll keep you posted!

[BhumikaMD]

Hi,

I know you must be going through a very tough emotional phase right now. But what you need to do is keep up hope and keep going on till you find the answers and the solution.

We hope the rheumatologist might be able to come to a diagnosis and then further treatment can be planned accordingly.

Good wishes.

Do let us know how the appointment goes and about how your son is doing now.

Regards.

[2isenough]

Thank you!!
I finally heard back from the nurse today.  My son's ASO titer was 928, A-DNase 686 and Sed rate 18.  While he was be evaluated by the Rheumatology doctors, they ordered a chest x-ray (everything good), referral to a dermatologist to make sure the nodules are Erythema Nodosum and referral to an opthamologist because some type of swelling behind the eye can cause some of these symptoms.  ???  Now, I have not had the opportunity to talk to any doctors.  The nurse said they would like to put him on Penicillin "to protect his heart" but from what, she could not tell me.  I still have many questions and no answers.  With an elevated A-DNase, I am thinking more along the lines of rheumatic fever (from my little bit of research).  Do you know of any other areas to explore?  Thanks again for your support!

[BhumikaMD]

Hi,

What other medications has he been prescribed? How is he doing now?

Have you seen a cardiologist as yet? This could be rheumatic fever - You would have to discuss this in detail with your doctor.

You could read up about rheumatic fever at-

http://en.wikipedia.org/wiki/Rheumatic_fever

Also, penicillin is given for prevention of recurrence of an attack of acute rheumatic fever and cardiac involvement.

Let us know if you have any other doubts and also post us about what your doctor advises.

Regards.

[dani9286]

My wife's age is 44.  She is suffering from low back pain, neck pain and frequently saying that she is feeling feverish.  She often feels some palpitations around the thyroid gland area (neck area).  The doctor advised me to take a  blood test for Rh factor and ASO TITER.  The result is "RH factor is negative and ASO TITER is positive".  I request you to explain me what may be the consequences with the ASO TITER positive.  Is there any need to go for the further blood test in detail. Give me some idea about the course of treatment, and any specialist consultation required.

Thanks and regards.

Daniel Raja Sekar.

***@****

[Angel13209]

Hello,
i-was-just-wondering-if-anyone-has-mentioned-Dercum's-Disease-(adiposis-dolarosa)?--I-had-the-same-symptoms-esp-the-pain-and-headaches-and-the-painful-nodules-on-the-legs.--My-nodules-are-painful-to-the-touch,-like-a-bruise,-sometimes-worse-and-are-not-red.--I've-been-to-every-kind-of-Dr-in-the-last-4-years-and-finally-got-the-diagnosis-of-Dercum's-Disease.--It-is-a-rare-disease-so-not-many-Drs-have-heard-about-it.--Google-Dercum's-Disease-and-read-and-see-if-it-matches-with-your-son.--It-might-be-something-of-interest.--Good-luck.--Don't-give-up!