Erythema nodosum: prospective study of 32 cases

Fernandes, Nurimar C.; Maceira, Juan; Muniz, Mauro de Medeiros

doi:10.1590/S0036-46651994000600006

Abstracts

The results of 32 cases studied lead us to the conclusion that erythema nodosum's investigation routine is very important, once in our retrospective study, the percentage of cases of unknown etiology was 69.4%, and in this prospective study it is 21.8%. In 10 cases (31.2%), more than one causing agent was suspected. Infections (bacterial, helminthic, fungal, by protozoa) were diagnosed in 26 cases, streptococcal infection having predominated (12 cases). Drugs-dipirone, aspirin, anovulatory - were suspected as causing agents in 13 cases. The association of erythema nodosum and histoplasmosis capsulata is described for the first time in Brazil. We consider erythema nodosum to be a complex syndrome which should be regarded as a manifestation of underlying diseases. The fact that all 32 subjects were women, 26 of them during menacme, suggests that particular hormonal media may favor the action of various processes (infections and drugs), precipitating erythema nodosum's clinical picture.

Erythema nodosum; Histoplasmosis capsulata

O estudo de 32 casos de eritema nodoso permite concluir que a rotina de investigação é extremamente importante já que em nosso estudo retrospectivo, o percentual de etiologia indeterminada foi de 69,4% e neste estudo prospectivo é de 21,8%. Em 10 casos (31,2%) mais de um agente causal foi suspeitado. Infecções (bacteriana, helmíntica, fúngica e por protozoário) foram diagnosticadas em 26 casos, tendo predominado a infecção estreptocócica com 12 casos. As drogas de suspeição foram dipirona, aspirina e anovulatório em 12 casos. A associação de eritema nodoso e histoplasmose capsulata é descrita pela primeira vez no Brasil. O eritema nodoso é síndrome complexa e deveria ser considerado sempre como manifestação de doença subjacente. A amostra de 32 pacientes exclusivamente do sexo feminino sendo que 26 em idade fértil sugere que vários processos (infecções e drogas) podem atuar em meio hormonal, particular e favorecedor, precipitando o quadro de eritema nodoso.

DERMATOLOGY

Erythema nodosum:prospective study of 32 cases

Eritema nodoso: estudo prospectivo de 32 casos

Nurimar C. Fernandes^I; Juan Maceira^II; Mauro de Medeiros Muniz^III

^IAdjunt Professor of Dermatology, Faculdade de Medicina da Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho

^IIAdjunt Professor of Pathology, Faculdade de Medicina da Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho

^IIIMycology Laboratory, Hospital Evandro Chagas - FIOCRUZ

^{Correspondence to} Correspondence to: Nurimar C. Fernandes Rua Alexandre de Gusmão, 28 apto. 201 20520-120 Tijuca - Rio de Janeiro, RJ, BRASIL

SUMMARY

The results of 32 cases studied lead us to the conclusion that erythema nodosum's investigation routine is very important, once in our retrospective study, the percentage of cases of unknown etiology was 69.4%, and in this prospective study it is 21.8%. In 10 cases (31.2%), more than one causing agent was suspected. Infections (bacterial, helminthic, fungal, by protozoa) were diagnosed in 26 cases, streptococcal infection having predominated (12 cases). Drugs-dipirone, aspirin, anovulatory - were suspected as causing agents in 13 cases. The association of erythema nodosum and histoplasmosis capsulata is described for the first time in Brazil. We consider erythema nodosum to be a complex syndrome which should be regarded as a manifestation of underlying diseases. The fact that all 32 subjects were women, 26 of them during menacme, suggests that particular hormonal media may favor the action of various processes (infections and drugs), precipitating erythema nodosum's clinical picture.

Keywords: Erythema nodosum; Histoplasmosis capsulata.

RESUMO

O estudo de 32 casos de eritema nodoso permite concluir que a rotina de investigação é extremamente importante já que em nosso estudo retrospectivo, o percentual de etiologia indeterminada foi de 69,4% e neste estudo prospectivo é de 21,8%. Em 10 casos (31,2%) mais de um agente causal foi suspeitado. Infecções (bacteriana, helmíntica, fúngica e por protozoário) foram diagnosticadas em 26 casos, tendo predominado a infecção estreptocócica com 12 casos. As drogas de suspeição foram dipirona, aspirina e anovulatório em 12 casos. A associação de eritema nodoso e histoplasmose capsulata é descrita pela primeira vez no Brasil. O eritema nodoso é síndrome complexa e deveria ser considerado sempre como manifestação de doença subjacente. A amostra de 32 pacientes exclusivamente do sexo feminino sendo que 26 em idade fértil sugere que vários processos (infecções e drogas) podem atuar em meio hormonal, particular e favorecedor, precipitando o quadro de eritema nodoso.

Full text available only in PDF format.

Texto completo disponível apenas em PDF.

Recebido para publicação em 16/03/1994

Aceito para publicação em 13/07/1994

1. ALINOVI, A.; LUI, P. & BENOLD, D. - Syphilis-still a cause of erythema nodosum. Int. J. Derm., 22: 310-311, 1983.
2. AREIAS, E. & GARCIA E SILVA, L. - Erythema nodosum and Crohn's disease. Med. cut. ibero. lat. amer., 12: 489-495, 1984.
3. AREIAS, E. & GARCIA E SILVA, L. - Erythema nodosum and ulcerative colitis. Acta med. port., 6: 143-147, 1985.
4. BONDI, E.E. & LAZARUS, G.S. - Panniculitis. In: FITZPATRICK, T.B.; EISEN, A.Z.; WOLFF, K.; FREEDBERG, J.W. & AUSTEN, K.F. - Dermatology in general medicine. 3. ed., New York, McGraw Hill, 1987. p. 1131-1148.
5. CASTILLA CORTAZAR, A.; PASTOR RODRIGUES, A. & AGUIRRE ERRASTI, C. - Erythema nodosum and Hodgkin's disease. Med. clín. (Barcelona), 85: 431-1985.
6. CERVIA, M.; PARODI, A. & REBORA, A. - Chronic active hepatitis and erythema nodosum. Arch. Derm., 118: 878, 1982.
⁷
CONTROLE DE HANSENÍASE - Uma proposta de integração de ensino: serviço. Rio de Janeiro, DNDS/NUTES, 1989.
⁸
CONTROLE DA TUBERCULOSE - Uma proposta de integração ensino: serviço. 2. ed. Rio de Janeiro, CNCT/NUTES, 1989.
9. DI GIUSTO, C.A. & BERNHARD, J.D. - Erythema nodosum provoked by hepatitis B vaccine. Lancet, 2: 1042, 1986.
10. DOBSON, H.M. & HUME, R. - Salmonella gastroenteritis associated with erythema nodosum. Brit. med. J., 286: 1146, 1983.
11. EASTMOND, C.J. & REID, T.M. - Campylobacter enteritis and erythema nodosum. Brit. med. J., 285: 1421-1422, 1982.
12. ELLIS, M.E.; POPE, J.; MOKASHI, A. & DUMBAR, E. - Campylobacter colitis associated with erythema nodosum. Brit. med. J., 285: 937, 1982.
13. ERNTELL, M.; LJUNGGREN, K.; GADD, T. & PERSSON, K. - Erythema nodosum - a manifestation of Chlamydia pneumoniae (strain Twar) infection. Scand. J. infect. Dis., 21: 693-696, 1989.
14. FOLCH, M.G.; BELESTEROS, F. & SAFFIE, P. - Eritema nodoso: experięncia com 50 casos. Rev. méd. Chile, 106: 854-860, 1978.
15. GELLERT, A.; GREEN, E.S.; BECK, E.R. & RIDLEY, C.M. - Erythema nodosum progressing to pyoderma gangrenosum as a complication of Crohn's disease. Postgrad. med. J., 59: 791-793, 1983.
16. GOODWIN, R.A.; LOYD, J.E. & DES PREZ, R.M. - Histoplasmosis in normal hosts. Medicine, 60: 231-266, 1981.
17. GOOLSBY, P.L. - Erythema nodosum after Recombivax HB hepatitis vaccine. New Engl. J. Med., 321: 1198-1199, 1989.
18. GORDON, H. - Erythema nodosum. A review of one hundred and fifteen cases. Brit. J. Derm., 73: 393-409, 1961.
19. GROSSMAN, M.E. & KATZ, B. - Salmonella enteritidis enterocolitis: another cause of diarrhea and erythema nodosum. Cutis, 34: 402-403, 1984.
20. HANNUKSELA, M. - Erythema nodosum with special reference to sarcoidosis. A clinical study of 343 Finnish adult patients. Ann. clin. Res., 3 (supl. 7): 5-64, 1971.
21. HARRIES, A.D. & TAYLOR, J. - Erythema nodosum associated with invasive amoebiasis and giardiasis. Brit. J. Derm., 114: 394, 1986.
22. IKEIA, T.; MIZUNO, E. & TAKAMA, H. - Three cases of erythema nodosum associated with Yersinia enterocolitica infection. J. Derm., 13: 147-150, 1986.
23. JAMES, D.G. - Erythema nodosum. Brit. med. J., 1: 853-857, 1961.
24. LARIO, B.A.; PINEY, E.; VALVERDE, V.R. & SAGREDO, J.L.P. - Eritema nodoso: estudo de 103 casos. Med. clin. (Barcelona), 88: 5-8, 1987.
25. LLORENS-TEROL, J. & MARTINEZ-ROIG, A. - Erythema nodosum associated with infectious mononucleosis. Helv. paediat. Acta, 38: 91-94, 1983.
26. MARTINEZ-ROIG, A.; LLORENS-TEROL, J. & TORRES, J.M. - Erythema nodosum and kerion of the scalp. Amer. J. Dis. Child., 136: 440-442, 1982.
27. MEDEIROS, A.A.; MARTY, S.D.; TOSH, F.E. & CHIN, T.D.Y. - Erythema nodosum and erythema multiforme as clinical manifestations of histoplasmosis in a community outbreak. New Engl. J. Med., 274: 415-420, 1966.
28. MONREAL, J.M. & DE LA SERNA, A.R. - Eritema nodoso. Revisión de 68 casos. Rev. clín. esp., 6: 405-408, 1983.
29. MONTEJO BARANDA, M.; GONZALES DE ZARATE APINANIZ, P.; PASCUAL VELASCO, F. & AGUIRRE ERRASTI, C. - Erythema nodosum associated with gastroenteristis caused by Salmonella enteritis: a new case. Med. clin., (Barcelona), 81: 412-413, 1983.
30. MORENO, A.J.; WEISMAN, I.; KENNEY, R.L. & FORT, S.L. - Concurrence of erythema multiforme and erythema nodosum. Cutis, 31: 275-278, 1983.
31. MORRISON, W.M.; MATHESON, J.A.; HUTCHINSON, R.B. & MACK, R.H. - Salmonella gastroenteritis associated with erythema nodosum. Brit. med. J., 286: 765, 1983.
32. MOSCHELLA, S.L. - Hypersensitivity and miscellaneous inflammatory disorders. In: MOSCHELLA, S.L.; PILLSBURY, D.M. & HURLEY, H.J. Dermatology. Philadelphia, W. B. Saunders, 1975. p. 385-408.
33. PARET MASANA, A.; SABRIA LEAL, M.; FERRANDO BARBERA, J. & REY-JOLY BARROSO, C. - Erythema nodosum and pregnancy. Rev. clín. esp., 182: 236-237, 1988.
34. PARK, R.K.; GOLTZ, R.W. & CAREY, T.B. - Unusual cutaneous infections associated with immunosuppressive therapy. Arch. Derm., 95: 345-350, 1967.
35. POTTAGE, J.C.; TRENHOLME, G.M.; ARONSON, I.K. & HARRIS, A.A. - Panniculitis associated with histoplasmosis and alpha 1 - antitrypsin deficiency. Amer. J. Med., 75: 150-153, 1983.
36. SCHVED, J.F.; BENOIST D'AZU, G.; BRUNEL, M. & VALLAT, G. - Hairy cell leukemia associated with tuberculosis, disclosed by erythema nodosum. Sem. Hôp. Paris, 59: 2716-2717, 1983.
37. SELLERS Jr., T.F.; PRICE Jr., W.N. & NEWBERRY Jr., W.M. - An epidemic of erythema multiforme and erythema nodosum caused by histoplasmosis. Ann. intern. Med., 62: 1244-1262, 1965.
38. STECKELBERG, J.M.; TERRELL, C.L. & EDSON, R.S. - Laboratory-acquired Salmonella typhimurium enteritis: association with erythema nodosum and reactive arthritis. Amer. J. Med., 85: 705-707, 1988.
39. TAMI, L.F. - Erythema nodosum associated with Shigella colitis. Arch. Derm., 121: 590, 1985.
40. TEYSSANDIER, R.; GUIDET, B.; PINTA, P. & OFFENSTADT, G. - Mycoplasma pneumoniae pneumopathy with severe anemia and erythema nodosum. Presse méd., 14: 1613, 1985.
41. VARELA ALONSO, C.; SANTILLANA LOPEZ, I.; DE ANDRES DE COLSA, R.; RUIZ DE AGUIAR & GONZALEZ, A. - Erythema nodosum in brucellosis. Med. clin., (Barcelona), 91: 437, 1988.
42. VERDEJO ORTES, J.; POLO RODRIGUEZ, R.M.; FENOY RODRIGUEZ, P.A. & GONZALEZ LAHOZ, J.M. - Erythema nodosum associated with Salmonella enteritidis gastroenteritis. Rev. clín. esp., 178: 151, 1986.
43. VESSEY, C.M.R. & WILKINSON, D.S. - Erythema nodosum. A study of seventy cases. Brit. J. Derm., 71: 139-155, 1959.
44. WANKE, B. - Histoplasmose: estudo epidemiológico, clínico e experimental. Rio de Janeiro, 1985. (Tese de doutoramento - Faculdade de Medicina da Universidade Federal do Rio de Janeiro).
45. WANKE, N.C.F.; FERNANDEZ, L. & BONAT, E.F. - Eritema nodoso: revisăo de 72 casos. An. bras. Derm., 64: 23-24, 1989.
46. WEINSTEIN, A.; BUJAK, D.; MITTELMAN, A. & DAVIDIAN, M. - Erythema nodosum in a patient with renal cell carcinoma treated with interleukin 2 and lymphokine activated killer cells. J. Amer. med. Ass., 258: 3120-3121, 1987.
47. WHEAT, L.J.; SLAMA, T.G.; EITZEN, H.E. et al. - A large urban outbreak of histoplasmosis. Clinical features. Ann. intern. Med., 94: 331-337, 1981.

Correspondence to:

Nurimar C. Fernandes

Rua Alexandre de Gusmão, 28 apto. 201

20520-120 Tijuca - Rio de Janeiro, RJ, BRASIL

Publication Dates

Publication in this collection
05 July 2006
Date of issue
Dec 1994

History

Received
16 Mar 1994
Accepted
13 July 1994

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. ALINOVI, A.; LUI, P. & BENOLD, D. - Syphilis-still a cause of erythema nodosum. Int. J. Derm., 22: 310-311, 1983.

[2] 2. AREIAS, E. & GARCIA E SILVA, L. - Erythema nodosum and Crohn's disease. Med. cut. ibero. lat. amer., 12: 489-495, 1984.

[3] 3. AREIAS, E. & GARCIA E SILVA, L. - Erythema nodosum and ulcerative colitis. Acta med. port., 6: 143-147, 1985.

[4] 4. BONDI, E.E. & LAZARUS, G.S. - Panniculitis. In: FITZPATRICK, T.B.; EISEN, A.Z.; WOLFF, K.; FREEDBERG, J.W. & AUSTEN, K.F. - Dermatology in general medicine. 3. ed., New York, McGraw Hill, 1987. p. 1131-1148.

[5] 5. CASTILLA CORTAZAR, A.; PASTOR RODRIGUES, A. & AGUIRRE ERRASTI, C. - Erythema nodosum and Hodgkin's disease. Med. clín. (Barcelona), 85: 431-1985.

[6] 6. CERVIA, M.; PARODI, A. & REBORA, A. - Chronic active hepatitis and erythema nodosum. Arch. Derm., 118: 878, 1982.

[7] ⁷
CONTROLE DE HANSENÍASE - Uma proposta de integração de ensino: serviço. Rio de Janeiro, DNDS/NUTES, 1989.

[8] ⁸
CONTROLE DA TUBERCULOSE - Uma proposta de integração ensino: serviço. 2. ed. Rio de Janeiro, CNCT/NUTES, 1989.

[9] 9. DI GIUSTO, C.A. & BERNHARD, J.D. - Erythema nodosum provoked by hepatitis B vaccine. Lancet, 2: 1042, 1986.

[10] 10. DOBSON, H.M. & HUME, R. - Salmonella gastroenteritis associated with erythema nodosum. Brit. med. J., 286: 1146, 1983.

[11] 11. EASTMOND, C.J. & REID, T.M. - Campylobacter enteritis and erythema nodosum. Brit. med. J., 285: 1421-1422, 1982.

[12] 12. ELLIS, M.E.; POPE, J.; MOKASHI, A. & DUMBAR, E. - Campylobacter colitis associated with erythema nodosum. Brit. med. J., 285: 937, 1982.

[13] 13. ERNTELL, M.; LJUNGGREN, K.; GADD, T. & PERSSON, K. - Erythema nodosum - a manifestation of Chlamydia pneumoniae (strain Twar) infection. Scand. J. infect. Dis., 21: 693-696, 1989.

[14] 14. FOLCH, M.G.; BELESTEROS, F. & SAFFIE, P. - Eritema nodoso: experięncia com 50 casos. Rev. méd. Chile, 106: 854-860, 1978.

[15] 15. GELLERT, A.; GREEN, E.S.; BECK, E.R. & RIDLEY, C.M. - Erythema nodosum progressing to pyoderma gangrenosum as a complication of Crohn's disease. Postgrad. med. J., 59: 791-793, 1983.

[16] 16. GOODWIN, R.A.; LOYD, J.E. & DES PREZ, R.M. - Histoplasmosis in normal hosts. Medicine, 60: 231-266, 1981.

[17] 17. GOOLSBY, P.L. - Erythema nodosum after Recombivax HB hepatitis vaccine. New Engl. J. Med., 321: 1198-1199, 1989.

[18] 18. GORDON, H. - Erythema nodosum. A review of one hundred and fifteen cases. Brit. J. Derm., 73: 393-409, 1961.

[19] 19. GROSSMAN, M.E. & KATZ, B. - Salmonella enteritidis enterocolitis: another cause of diarrhea and erythema nodosum. Cutis, 34: 402-403, 1984.

[20] 20. HANNUKSELA, M. - Erythema nodosum with special reference to sarcoidosis. A clinical study of 343 Finnish adult patients. Ann. clin. Res., 3 (supl. 7): 5-64, 1971.

[21] 21. HARRIES, A.D. & TAYLOR, J. - Erythema nodosum associated with invasive amoebiasis and giardiasis. Brit. J. Derm., 114: 394, 1986.

[22] 22. IKEIA, T.; MIZUNO, E. & TAKAMA, H. - Three cases of erythema nodosum associated with Yersinia enterocolitica infection. J. Derm., 13: 147-150, 1986.

[23] 23. JAMES, D.G. - Erythema nodosum. Brit. med. J., 1: 853-857, 1961.

[24] 24. LARIO, B.A.; PINEY, E.; VALVERDE, V.R. & SAGREDO, J.L.P. - Eritema nodoso: estudo de 103 casos. Med. clin. (Barcelona), 88: 5-8, 1987.

[25] 25. LLORENS-TEROL, J. & MARTINEZ-ROIG, A. - Erythema nodosum associated with infectious mononucleosis. Helv. paediat. Acta, 38: 91-94, 1983.

[26] 26. MARTINEZ-ROIG, A.; LLORENS-TEROL, J. & TORRES, J.M. - Erythema nodosum and kerion of the scalp. Amer. J. Dis. Child., 136: 440-442, 1982.

[27] 27. MEDEIROS, A.A.; MARTY, S.D.; TOSH, F.E. & CHIN, T.D.Y. - Erythema nodosum and erythema multiforme as clinical manifestations of histoplasmosis in a community outbreak. New Engl. J. Med., 274: 415-420, 1966.

[28] 28. MONREAL, J.M. & DE LA SERNA, A.R. - Eritema nodoso. Revisión de 68 casos. Rev. clín. esp., 6: 405-408, 1983.

[29] 29. MONTEJO BARANDA, M.; GONZALES DE ZARATE APINANIZ, P.; PASCUAL VELASCO, F. & AGUIRRE ERRASTI, C. - Erythema nodosum associated with gastroenteristis caused by Salmonella enteritis: a new case. Med. clin., (Barcelona), 81: 412-413, 1983.

[30] 30. MORENO, A.J.; WEISMAN, I.; KENNEY, R.L. & FORT, S.L. - Concurrence of erythema multiforme and erythema nodosum. Cutis, 31: 275-278, 1983.

[31] 31. MORRISON, W.M.; MATHESON, J.A.; HUTCHINSON, R.B. & MACK, R.H. - Salmonella gastroenteritis associated with erythema nodosum. Brit. med. J., 286: 765, 1983.

[32] 32. MOSCHELLA, S.L. - Hypersensitivity and miscellaneous inflammatory disorders. In: MOSCHELLA, S.L.; PILLSBURY, D.M. & HURLEY, H.J. Dermatology. Philadelphia, W. B. Saunders, 1975. p. 385-408.

[33] 33. PARET MASANA, A.; SABRIA LEAL, M.; FERRANDO BARBERA, J. & REY-JOLY BARROSO, C. - Erythema nodosum and pregnancy. Rev. clín. esp., 182: 236-237, 1988.

[34] 34. PARK, R.K.; GOLTZ, R.W. & CAREY, T.B. - Unusual cutaneous infections associated with immunosuppressive therapy. Arch. Derm., 95: 345-350, 1967.

[35] 35. POTTAGE, J.C.; TRENHOLME, G.M.; ARONSON, I.K. & HARRIS, A.A. - Panniculitis associated with histoplasmosis and alpha 1 - antitrypsin deficiency. Amer. J. Med., 75: 150-153, 1983.

[36] 36. SCHVED, J.F.; BENOIST D'AZU, G.; BRUNEL, M. & VALLAT, G. - Hairy cell leukemia associated with tuberculosis, disclosed by erythema nodosum. Sem. Hôp. Paris, 59: 2716-2717, 1983.

[37] 37. SELLERS Jr., T.F.; PRICE Jr., W.N. & NEWBERRY Jr., W.M. - An epidemic of erythema multiforme and erythema nodosum caused by histoplasmosis. Ann. intern. Med., 62: 1244-1262, 1965.

[38] 38. STECKELBERG, J.M.; TERRELL, C.L. & EDSON, R.S. - Laboratory-acquired Salmonella typhimurium enteritis: association with erythema nodosum and reactive arthritis. Amer. J. Med., 85: 705-707, 1988.

[39] 39. TAMI, L.F. - Erythema nodosum associated with Shigella colitis. Arch. Derm., 121: 590, 1985.

[40] 40. TEYSSANDIER, R.; GUIDET, B.; PINTA, P. & OFFENSTADT, G. - Mycoplasma pneumoniae pneumopathy with severe anemia and erythema nodosum. Presse méd., 14: 1613, 1985.

[41] 41. VARELA ALONSO, C.; SANTILLANA LOPEZ, I.; DE ANDRES DE COLSA, R.; RUIZ DE AGUIAR & GONZALEZ, A. - Erythema nodosum in brucellosis. Med. clin., (Barcelona), 91: 437, 1988.

[42] 42. VERDEJO ORTES, J.; POLO RODRIGUEZ, R.M.; FENOY RODRIGUEZ, P.A. & GONZALEZ LAHOZ, J.M. - Erythema nodosum associated with Salmonella enteritidis gastroenteritis. Rev. clín. esp., 178: 151, 1986.

[43] 43. VESSEY, C.M.R. & WILKINSON, D.S. - Erythema nodosum. A study of seventy cases. Brit. J. Derm., 71: 139-155, 1959.

[44] 44. WANKE, B. - Histoplasmose: estudo epidemiológico, clínico e experimental. Rio de Janeiro, 1985. (Tese de doutoramento - Faculdade de Medicina da Universidade Federal do Rio de Janeiro).

[45] 45. WANKE, N.C.F.; FERNANDEZ, L. & BONAT, E.F. - Eritema nodoso: revisăo de 72 casos. An. bras. Derm., 64: 23-24, 1989.

[46] 46. WEINSTEIN, A.; BUJAK, D.; MITTELMAN, A. & DAVIDIAN, M. - Erythema nodosum in a patient with renal cell carcinoma treated with interleukin 2 and lymphokine activated killer cells. J. Amer. med. Ass., 258: 3120-3121, 1987.

[47] 47. WHEAT, L.J.; SLAMA, T.G.; EITZEN, H.E. et al. - A large urban outbreak of histoplasmosis. Clinical features. Ann. intern. Med., 94: 331-337, 1981.