Rosen & Barkin's 5-Minute Emergency Medicine Consult (256 page)

Careful history and physical exam directed at detecting precipitating cause

• CBC
  
• Throat culture/ASO titer
  
• ESR
  
• Appropriate chemistry tests
  
• Liver function tests
  
• Serologies for coccidioidomycosis in endemic regions
  
• TB skin testing in endemic regions
  

CXR: Hilar adenopathy may be evidence of sarcoidosis, coccidioidomycosis, tuberculosis, or other fungal infections.

Definitive diagnosis made by deep elliptical biopsy and histopathologic evaluation (punch biopsy may be inadequate): Usually indicated for atypical cases or when TB is being considered

• EN migrans and chronic EN
  
• Any type of panniculitis can resemble EN.
  
• Differences can be determined histopathologically.
  
• Other disorders include:
  
  • Periarteritis nodosum
    
  • Migratory thrombophlebitis
    
  • Superficial varicose thrombophlebitis
    
  • Scleroderma
    
  • Systemic lupus erythematosus
    
  • α
    ₁
    -antitrypsin deficiency
    
  • Behcçet syndrome
    
  • Lipodystrophies
    
  • Leukemic infiltration of fat
    
  • Panniculitis associated with steroid use, cold, and infection
    

TREATMENT

• Rare in children,
  S
  .
  pharyngitis
  is the most likely etiology.
  
• Catscratch disease should be considered.
  

Maintain universal precautions

Airway, breathing, and circulation (ABCs); IV, oxygen, monitoring as appropriate

• Treatment should be directed at underlying disease.
  
• Supportive therapies include rest and analgesics.
  
• Corticosteroids and potassium iodide may hasten resolution of symptoms.
  
• Systemic corticosteroids are contraindicated in the presence of certain underlying infections such as TB or coccidioidomycosis, which may disseminate with their use.
  
• Potassium iodide is contraindicated in hyperthyroid states.
  

• Aspirin: 650 mg PO q4–6h PRN (peds: contraindicated)
  
  • Do not exceed 4 g/24 h
    
• Ibuprofen: 400–800 mg PO q8h (peds: 5–10 mg/kg PO q6h)
  
• Indomethacin: 25–50 mg PO q8h
  
• Potassium iodide/SSKI (used for resistant disease; contraindicated in hyperthyroidism): 900 mg PO daily for 3–4 wk
  
• Systemic corticosteroids (prednisone): 40 mg/d PO; duration determined by primary physician
  

• Rest/supportive care
  
• NSAIDs
  
• Treatment of underlying disease
  

• Potassium iodide
  
• Steroids
  

FOLLOW-UP

Dictated by the severity of symptoms and the etiologic agent

• Nontoxic patients, able to take PO fluids without difficulty
  
• Scheduled follow-up should be arranged.
  

• EN is usually self-limited and resolves in 3–6 wk.
  
• Atypical cases may need excisional biopsy.
  
• Steroid and potassium therapy needs primary physician monitoring.
  

• Follow-up to assess for resolution with primary care physician or dermatologist.
  
• Evaluation of underlying etiology may require specialist referral.
  

• EN is usually idiopathic but may be the 1st sign of systemic disease.
  
• Lesions may recur if underlying disease is not treated.
  
• Atypical and chronic lesions may indicate an alternative diagnosis and need biopsy.
  
• Patients taking potassium or steroids need close follow-up.
  

• Gilchrist H, Patterson JW. Erythema nodosum and erythema induratum (nodular vasculitis): Diagnosis and management.
  Dermatol Ther
  . 2010;23(4):320–327.
  
• James JD, Berger TG, Elston DM.
  Andrew’s Disease of the Skin: Clinical Dermatology
  , 10th ed. Philadelphia, PA: WB Saunders; 2006.
  
• Mert A, Kumbasar H, Ozaras R, et al. Erythema nodosum: An evaluation of 100 cases.
  Clin Exp Rheumatol
  . 2007;25:563–570.
  
• Sarret C, Barbier C, Faucher R, et al. Erythema nodosum and adenopathy in a 15-year-old boy: Uncommon signs of cat scratch disease.
  Arch Pediatr
  . 2005;12:295–297.
  
• Schwartz RA, Nervi SJ. Erythema nodosum: A sign of systemic disease.
  Am Fam Physician
  . 2007;75:695–700.
  

CODES

• 017.10 Erythema nodosum with hypersensitivity reaction in tuberculosis, unspecified
  
• 695.2 Erythema nodosum
  

BASICS

• Adult esophagus is ∼25–30 cm in length in close proximity to mediastinum with access to pleural space.
  
• It begins at hypopharynx posterior to larynx at level of cricoid cartilage.
  
• On either side of this slit are piriform recesses:
  
  • May be site for foreign body to lodge
    
• Sites of esophageal narrowing:
  
  • Cricopharyngeal muscle (upper esophageal sphincter)
    
  • Crossover of left main stem bronchus and aortic arch
    
  • Gastroesophageal junction (lower esophageal sphincter)
    
  • Areas of disease (cancer, webs, or Schatzki ring)
    
• Upper 3rd of esophagus is striated muscle:
  
  • Initiates swallowing
    
• Middle portion is mixture of striated and smooth.
  
• Distal portion is smooth muscle.
  
• It is a fixed structure, but can become displaced by other organs:
  
  • Goiter
    
  • Enlarged atria
    
  • Mediastinal masses
    

• External forces or agents (30%):
  
  • Penetrating: Leading to tears:
    
    • Stab wounds
      
    • Missile wounds
      
  • Perforation:
    
    • Foreign bodies via direct penetration
      
    • Pressure necrosis
      
    • Chemical necrosis
      
    • Radiation necrosis from selective tissue ablation
      
    • Instrumentation
      
  • Blunt: Motor vehicle accident
    
• Internal forces or agents:
  
  • Caustic ingestions/burns:
    
    • Acid pH < 2, alkali pH > 12 accidental or intentional
      
    • Alkali (42%): Liquefaction necrosis causing burns, airway edema or compromise, perforation, chronic stricture, and cancer
      
    • Acid (32%): Coagulation necrosis, thermal injury, and dehydration causing perforation, ulceration, and infection, more likely to perforate than alkali
      
    • Chlorine bleach (26%): Mucosal edema, superficial erythema
      
  • Infections:
    
    • Viruses (CMV, HPV, and HSV) or fungi in immunocompromised patients
      
  • Drugs:
    
    • Less common but case series reported
      
    • Alendronate, Doxycycline, NSAIDs
      
    • Mycophenolate mofetil
      
    • May cause esophageal erosion or esophagitis
      
  • Swallowed agents:
    
    • Food bolus impaction:
      
    • Coins, bones, buttons, marbles, pins, button batteries
      
  • Most common type is meat.
    
• In adults: Prisoners, psychiatric patients, intoxicated patients, or edentulous patients
  
• Iatrogenic (55%):
  
  • Perforation secondary to instrumentation, endoscopy most common cause
    
  • Nasotracheal intubation/nasogastric (NG) tube most common cause in emergency department
    
• Increased gastric pressure (15%):
  
  • Large pressure differences between thorax and intra-abdominal cavity:
    
    • May lead to lacerations or perforation
      
  • Mallory–Weiss syndrome:
    
    • Longitudinal tears in distal esophageal mucosa with bleeding
      
  • Boerhaave syndrome:
    
    • Spontaneous esophageal rupture
      
    • Full-thickness rupture of distal esophagus
      
    • Classically after alcohol or large meals and vomiting
      

• Foreign bodies
  
  • Accounts for 75–80% of swallowed foreign bodies:
    
  • Typically in infants ages 18–48 mo
    
  • Entrapment usually at upper esophageal sphincter
    
  • Perforations
    
  • Commonly iatrogenic with NG insertion, stricture dilation, and endotracheal intubation
    
• Caustic ingestions
  
  • More common in children <5 yr
    
  • Button batteries highly alkaline and need removal if lodged in esophagus within 4–6 hr
    
  • Packets of single use laundry/dishwasher detergents are prevalent with AAPCC issuing safety warning