Erythema Nodosum – A Clinical Case Study with Reflections

Abstract: The purpose of this case study is to encourage the modern acupuncturist to perform a thorough History & Physical exam (H & P), approach each patient with kindness and honesty, admit when there are unfamiliar concepts and findings, know when to treat, how to treat, and when to refer. The importance of a thorough and detailed H & P cannot be over emphasized. Question-Asking, Observation, and Palpation are some of the diagnostic techniques taught in Chinese Medical Schools. As basic as these techniques are, they are some of the most crucial skills to incorporate with each patient interaction. Even the most astute clinician needs to be focused on the full set of data points prior to making a diagnosis and pursuing a treatment strategy. The Law of the Instrument is often well appreciated and understood in the medical community. The surgeon recommends surgery. The homeopath recommends homeopathic remedies. The acupuncturist recommends acupuncture. Of course, as clinicians we can be biased to use tools that are within our own “tool box.” When choosing a tool to use, how wonderful to choose one with which we are not only familiar, but one we already possess! Upon examining the contents of your tool box, it is important to not only see what IS there, but to see what IS NOT there. To illustrate this concept in action, let’s meet Katie.

“I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” – Abraham H. Maslow (1966)i

THE FIRST PATIENT ENCOUNTER

Email is often my first interaction with a potential new patient. It was January 7, 2015 at 09:06am when I received an email from Katie:

“Hi Amy,

I was hoping to set-up an appointment with you at your earliest availability. Here’s my situation: Last month, I was working out rather strenuously as I was participating in a 30-day workout challenge. The nature of the exercise is barre (Dailey Method). I’ve been doing this for about 4.5 years, and have never experienced any issues. A few weeks ago, I had a particularly intense workout, and found that both of my knees and ankles felt really tight afterwards. The tightness continued, but this was rather normal and I expected it would subside in a few days. Over the past week, the situation has accelerated into really swollen ankles (particularly on the left side), and has made walking rather unbearable. I went to see a traditional doctor to make sure I didn’t injure my ankle/s, but they were rather dismissive and just said to rest. I would love another opinion, especially one that encompasses a natural healing process. I have never tried acupuncture, but am absolutely open to whatever seems like the right course of action. Please let me know when you might be able to see me. I am working from home today, and can easily get there if there is any availability.

Thanks much,

Katie M.”

There were many details in Katie’s email that immediately engaged my attention. First of all, she was a good historian. I noticed that she had been experiencing symptoms for a few weeks, worsening in intensity. This fact demonstrated to me that this was not an acutely life threatening injury, and possibly a good fit for me as a clinician. She explained that the pain was in her knees and ankles and feels “tight.” The symptoms were progressing, and she reported swelling that was increasing, L>R, and that walking had become “rather unbearable.” That language caught my attention. “Unbearable” is obviously a subjective descriptor, however it illustrates the intensity of the pain. Katie also explained that she had already seen a traditional doctor, which I later discovered was a medical doctor (MD). This fact was “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” – Abraham H. Maslow (1966)i OM CLINICAL MEDICINE also reassuring to me. Lastly, I knew that if she was experiencing anything really serious or concerning that the MD surely would have diagnosed and treated accordingly. Of course, I agreed to see her later that same day.

Now that you have been introduced to Katie, let’s get back to the toolbox.

THE TOOLBOX

What clinical tools do you have that are most familiar, accessible, and valuable to you? As an acupuncturist, you may answer this question by listing:

• Acupuncture needles
• Electric stimulation
• Moxibustion
• Cupping
• The Materia Medica

This list, although not exhaustive, is an appropriate answer to the question. However – this list is also a list of potential interventions. In other words, these interventions are therapeutic tools.

In clinical practice, there are some other tools in your toolbox that will also serve you well—diagnostic tools. Some of the most dependable diagnostic tools you already possess include:

• Question-Asking
• History Taking
• Physical exam including palpation, listening, observation, and data collection
• Intuition

The benefits of using each of these tools mindfully cannot be overemphasized. Whether you are a new acupuncturist or a seasoned acupuncturist, proper use of diagnostic tools will always help you choose from the therapeutic tools with more ease and effectiveness.

The differentiation between diagnostic and therapeutic tools may seem obvious and completely unnecessary. However – in my experience—I have found this exact differentiation to be critical in identifying who needs treatment, and what treatment they require.

MAVERICKS OF MEDICINE

In my career, I have had the privilege of working in some of the most prestigious teaching hospitals in the nation.

Here is an anecdote that demonstrates this concept quite well from my experience working as a clinical instructor for the paramedic program in 2003. Each shift, I was assigned three paramedic students to train in the emergency department at the level-one trauma center in San Francisco, California. Each time I would ask, “What would you like to learn today?” And the answer would always be, “IV’s!” (intravenous catheter placement.) Every trauma nurse and paramedic eventually masters this skill. It is indeed an important and potentially life-saving intervention for many a patient. And, I knew that each of these paramedic mavericks would master it in six to eight months no matter what I taught them on this particular day. With this in mind I would then softly explain, “Placing an IV is a skill you will soon master, but what good is this skill if you don’t know which patient actually needs an IV?”

Complete silence. Every time.

Instead of placing IV’s for ten hours, I would always recommend that we spend our time more thoughtfully by assessing patients, asking questions, auscultating lung and heart sounds, and paying attention to other subtle findings such as moist skin and a mild grimace on the face. Oftentimes, these data points collected through a history and physical exam are the most revealing when determining what interventions are not only appropriate, but actually indicated.

I share this story because focusing on assessing a patient properly will facilitate the clinician to reach for the right tool at the right time. Whatever the credentials or licenses you may hold, having good assessment skills will always serve you well. Performing a thorough history and physical exam is a critical step for both seasoned and inexperienced clinicians.

KATIE’S VISIT

Fortunately, I was able to see Katie sameday, and offered her an appointment for consultation and treatment at my BiaoHealth clinic in San Francisco.

Katie is a 45-year old female with no previous medical history. She is in good physical shape, and exercises daily. She is alert, articulate, and well-appearing upon initial observation. Her breathing is even and unlabored. Her skin is appropriately pink. She looks well-nourished and seems to be an appropriate weight for her height. She makes eye-contact and answers questions appropriately. As we used to say in the hospital setting, “She eyeballs well,” meaning—she looks good. She does not look ill or sick. That being the case, we proceed with the formal consultation.

The history taking reveals some further details about her relationship to exercise, when the pain started, and the actual physical activity of the barre 30-day challenge (Dailey Method). I was previously unfamiliar with this type of exercise—and this of course prompted me to inquire more about the routine. This exercise sounds rigorous and challenging; a type of cardioaerobics workout with some impact from body weight and gravity—but definitely not the type of clinical picture that leads to an injury, per se.

After completing her consultation, I escorted Katie to the acupuncture treatment suite. Once she was settled comfortably onto the table, I proceeded to obtain pulse and tongue diagnosis data points. Her pulse was wiry. The tongue was red, slightly dry, and without a substantial fur coating. The red color a bit more beefy red than I expected to find. I documented her resting heart rate at 80-BPM. I then continued onward with my physical assessment. I explained that I would be exposing her legs to assess her knees and ankles.

As I lifted up the sheet and blanket to expose her lower extremities, my jaw dropped. I was stunned by what I found. Physical exam revealed two very abnormal appearing lower extremities. There were multiple erythematous swollen nodules of various sizes—from marble size to golf-ball size scattered about her lower extremities, bilaterally, below the knees. They had the consistency of lipomas, dense, but movable. They varied in size but also in the color of red. Some were more of a sunburn-red erythema, and others had “faded” almost to a purplish-red typical of a bruise. Not only were there erythematous nodules, but I also found that her legs were especially swollen, edematous and tight, the left more-so than the right. As I began to assess this situation further, I placed my hand on her left ankle. Hot to the touch. This was definitely the most concerning, as I was sure there was some type of inflammation, and perhaps even infection. It was not clear. But one thing that was clear: These were NOT the legs I was expecting to find.

I paused. I was thinking so many different things all at once. I wanted to reassure Katie that I could help her. She must have been in a lot of pain! These legs looked painful! Very painful! She is most definitely a stoic person, and I was trying to understand how she had been walking on those legs at all. She explained that it felt like “handcuffs around her ankles.” It took me no time at all to realize that her story didn’t match the physical findings. There was no way that those legs were simply the result of a strenuous workout. There was something much more systemic underlying the presentation. The entire exercise story, although a true recount of historical events, may have had nothing to do with this patient’s presentation.

I still had my hand on her left ankle, proceeding with lower extremity pulse assessments, as I asked, “You mentioned that you saw a medical doctor just two days ago. Is that right? Did your legs look like this two days ago when you saw the doctor?” She tells me yes. I next mentioned the red nodules on her legs. She honestly replied that this was not her focus, that really the ankles were the most painful. She then explained to me that the doctor did not look at her legs. The doctor instead told her that she should rest and perhaps take some ibuprofen to reduce the swelling and pain.

The doctor didn’t assess her legs? I was shocked. I immediately understood my assumption that nothing serious could be going on because she had been evaluated by a medical doctor was not necessarily reliable.

INTUITION – THE VISCERAL TOOL

I have seen many legs over the years – many legs on many people, and I can tell you that I had never seen any legs that looked just like Katie’s legs. So, that being said, I wasn’t sure “what” my physical assessment had revealed.

I will always be grateful that my intuition has been so available and reliable. Even though it was not clear to me what the underlying manifestation of Katie’s condition was, I was confident that acupuncture was not appropriate in this case.

THE SHARPEST TOOL

I explained to Katie that I felt that a medical doctor (MD) needed to examine her legs and that she likely required a thorough work-up for this presentation. “Our bodies give us symptoms for a reason,” I explained. “We have an opportunity to listen to our bodies. And right now, your body is proclaiming that something is wrong.” I also explained to Katie that I was determined to help her, and with that being said, I felt that acupuncture was completely out of the question on that visit. I explained that we could very likely do acupuncture at some time in the future but today was not the day. This was of course a delicate matter because I did not want to disappoint her.

I had already used the most valuable tool in my toolbox, physical assessment and taking a good history I had also already decided which tool I was NOT using: Acupuncture. Fortunately, I had some other accessible tools, and offered Katie some sound therapy and guided imagery meditation for fifteen or twenty minutes. She had already come all this way to see me and finally lying on the table must have been a brief respite from the pain—so this solution made sense to me. Katie agreed.

During Katie’s guided imagery session, I was engrossed in my literature scrub on the internet and in my textbooks trying to determine what this assessment finding was that I had never seen before. Fortunately for me, the answer actually came very quickly – and I was fairly confident that I had found the answer: Erythema Nodosum (EN).

ERYTHEMA NODOSUM

Erythema Nodosum – (definition) Red, painful nodules on the legs.ii I read the description of EN in Taber’s Medical dictionary—and realized at this point, EN is not a disease, but an assessment finding.

[Generally, EN is idiopathic, although the most common identifiable cause is streptococcal pharyngitis. Erythema nodosum may be the first sign of a systemic disease such as tuberculosis, bacterial or deep fungal infection, sarcoidosis, inflammatory bowel disease, or cancer. Certain drugs, including oral contraceptives and some antibiotics, also may be etiologic. The hallmark of erythema nodosum is tender, erythematous, subcutaneous nodules that typically are located symmetrically on the anterior surface of the lower extremities. Erythema nodosum does not ulcerate and usually resolves without atrophy or scarring. Most direct and indirect evidence supports the involvement of a type IV delayed hypersensitivity response to numerous antigens.]iii

It would be comparable to seeing hives for the first time. Hives is an assessment finding that indicates a histamine release of a nonspecific etiology. EN is an assessment finding, and requires investigation. Sometimes the etiology is unknown, and in any case it does require an extensive workup.

I knew that the best way for me to help Katie was to refer. I explained to her the importance of requesting additional examination and testing by an MD as well as the importance of following up immediately— meaning tomorrow morning. I prepared a letter for her to take to her doctor for her convenience. I explained to Katie that sometimes I never know exactly how I’m going to help someone—the “how” reveals itself later. But for Katie, the answer was clear. She needed me to do a good physical assessment and refer her to an MD.

THE REFERRAL

In the referral letter for Katie’s doctor, I conveyed the subjective and objective assessment findings and encouraged a comprehensive evaluation and diagnostic work-up. I shared that I was concerned that it was a presentation of Erythema Nodosum with the hopes that she would be evaluated thoroughly for her symptoms and underlying etiology. I accompanied the letter with the following recommendations to be included in her diagnostic work-up:

• CBC with differential
• CXR
• Stool examination
• ESR
• CRP
• Serum CA++
• ACE
• Coagulation Panel

THE DIAGNOSIS & TREATMENT

Katie was well received by the medical doctors at her primary care clinic. In fact, she was seen immediately—the following day after meeting with me. She tells me that the doctor was appreciative of the letter I had written and proceeded to order not only the bloodwork and radiological studies I had recommended, but also included a 3-view x-ray series of her left ankle, an x-ray and CT scan of the chest, a referral to a Rheumatologist, and eventually an Ophthalmologist. Katie was started on a pharmaceutical called meloxicam to reduce the swelling. Additionally, a steroid, prednisone was prescribed, although Katie was resistant to using the steroid unless absolutely necessary. For those readers that may be interested in the detailed results of the bloodwork; her chemistry panel was unremarkable, the Complete Blood Count (CBC) was also unremarkable, aside from an elevated platelet count at 469. Her C-Reactive protein (CRP) however was elevated at 13.4, which was significant. Liver Function Tests (LFTs) completely normal. The results of the radiologic studies were thorough and conclusive.

Katie continued her diagnostic work-up and was eventually diagnosed with Erythema Nodosum consistent with Sarcoidosis.

She was in complete remission after several weeks of our initial encounter. Her chest CT was negative, and she ruled-out for any additional complications. The good news is that it has now been nearly one year since Katie first walked into my clinic, and she routinely sees me for acupuncture in promoting health and wellness, and stress management. Katie still loves the sound therapy and guided imagery as well as the acupuncture treatments. She is considering a full diagnostic evaluation through a Functional Medicine lens, which we will likely pursue together in 2016.

CONCLUSION

An acupuncturist needs to know when NOT to treat with acupuncture. An acupuncturist needs to be mindful of other tools that may be beneficial for the patient. Sometimes this includes listening to a patient’s story, implementing non-needle modalities such as sound therapy or guided imagery, and most importantly—when to refer. Remember, there will always be clinical presentations with which you are unfamiliar. It’s okay not to know everything. But pay attention to your intuition, and it will serve you well.

DISCUSSION

For you, the new or seasoned acupuncturist, I am hopeful that my case study encourages you to examine the tools in your toolbox. Which are you using most often? Which are getting dull? Which need to be sharpened? Do you need some new tools? Do you have more therapeutic tools than diagnostic tools? How much can you rely on your diagnostic tools? What about your own intuition? How often do you refer to other clinical specialists? Do you know when you don’t know? What is the best you can do for each patient with each encounter?

It’s true that experience is valuable. In fact, my clinical experience has created a lot of buoyancy for me in private practice. The truth is that even with twenty years’ experience in emergency nursing, there will always be a clinical presentation in my acupuncture practice that I have never seen. This patient encounter is one I will never forget. I am grateful that I trusted my intuition, that I knew how to help Katie, and that she benefited from my interventions. I am also grateful for the opportunity to share this with you and I hope that this case study benefits you and your patients in some way.

References

i. Abraham Maslow. The Psychology of Science: A Reconnaissance. Chapel Hill, NC: Maurice Bassett Publishing. 1969.

ii. Taber’s Cyclopedic Medical Dictionary, 18th Edition. FA Davis Company. 1997, p. 668.

iii. Robert A. Schwartz, M.D., M.P.H., and Stephen J. Nervi, M.D. Erythema Nodosum: A Sign of Systemic Disease. Am Fam Physician. 2007 Mar 1;75(5):695-700.