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Histopathologic Features of Erythema Nodosum–Like Lesions in Behçet Disease: A Comparison With Erythema Nodosum Focusing on the Role of Vasculitis

Many patients with Behçet disease (BD) develop lesions that clinically resemble those of erythema nodosum (EN) but differ from that condition with regard to their microscopic features. We examined 11 sections of EN-like lesions in BD and compared them with 9 sections of classic EN using routine histopathology and immunohistochemistry so as to form a comprehensive picture of the pathologic findings in BD and to determine the role of vasculitis in the formation of lesions. Erythema nodosum–like lesions of BD are characterized by panniculitis, usually lobular or mixed septal and lobular in pattern, with variable numbers of neutrophils, lymphocytes, and histiocytes as well as variable numbers of necrotic adipocytes. Vasculitis was noted in most EN-like lesions in BD. Scattered vessels showing lymphocytic vasculitis were evident in 6 sections, and foci of leukocytoclastic vasculitis were obvious in 4 sections, sometimes with phlebitis or arteriolitis. In specimens with classic EN, we did not observe vasculitis. Only the percentages of CD3+ lymphocytes and chloroacetate esterase–positive neutrophils in the infiltrating cells showed statistically significant differences (P < 0.05) between EN-like lesions in BD and EN through immunohistochemical and enzyme cytochemical studies. Because vasculitis in the EN-like lesions in BD was extensive and not limited to areas of severe inflammation, we believe that it is primary vasculitis. We suggest that vasculitis is an important pathologic event in EN-like lesions in BD but cannot determine the extent to which other pathologic changes such as septal or lobular panniculitis, fat necrosis, neutrophilic infiltration, or microabscess formation are secondary features.