Granuloma annulare associated with Hodgkin's disease.

Abstract

A 39‐year‐old man was referred to our institution for treatment of Hodgkin's disease (HD) previously diagnosed at another hospital. On physical examination the patient had bilateral cervical lymphadenopathy (9 cm to 0.5 cm in size), but no clinical hepatosplenomegaly was noted. Examination of his skin showed indurated reddish macules and papules scattered over the trunk and buttocks (Fig. 1).Laboratory examination showed a hemoglobin of 13.9 g/100 mL, with a leukocyte count of 8600/mm3 with 69% neutrophils, 9% eosinophils, 2% monocytes, 22% lymphocytes, and 2% abnormal lymphocytes. The platelet count was 398 × 103/mm3. The serum IgG was 1877 g/100 mL, the IgA was 572.5 g/100 mL, and the IgM was 55.5 g/100 mL, Serum test for HTLV‐1 antibody was positive, but hepatitis B antigen and hepatitis C antibodies were negative, A 67Ga scintigram showed uptake in the supraclavicular and right retrocervical areas. Computed tomographic scans showed bilateral cervical lymph node and left axillary lymph node enlargement. Bone marrow aspiration was normal.A lymph node biopsy specimen from the left axillary region showed partially effaced lymph node architecture with a few immature or atypical mononuclear cells and some Reed‐Stemberg cells. Necrosis and fibrosis was not seen (Fig. 2), The diagnosis of HD, lymphocyte predominant subtype, was therefore confirmed and he was staged as HD‐IIA.Biopsies were also obtained from the skin of his back and abdominal wall which showed perifollicular and perivascular cellular infiltration composed of mature small lymphocytes, epithelioid histiocytes, and multinucleated giant cells. Neither Hodgkin cells nor Reed‐Sternberg cells were recognized in the lesional skin. Collagen bundles lying in the upper dermis and close to the adipose tissue showed focal necrobiotic change particularly in the center of the infiltration (Fig. 3).Alcian‐blue stain confirmed acid mucopolysuccharide deposition on and between degenerated collagen bundles. Special stains for fungus and mycobacterium were negative.Immunohistochemically, the epithelioid histiocytes and multinucleated giant cells labelled positive for HLA‐DR in the membrane and were positive for lysozyme and alpha‐1 antichymotrypsin in the cytoplasm. Intermingled with these cells, S100a positive dendritic cells were also present, especially around hair follicle. The lymphocytes were immunoreactive with UCHL‐1 (CD45RO), Leu3 (CD4), and Leu4 (CD3), However, only a few lymphocytes stained with Leu3a (CD8), These findings of the skin lesions were consistent with those of granuloma annulare (GA).The patient was started on combination chemotherapy ABVD (adriamycin, bleomycin, vinblastin, and DTIC) for the HD, After 10 courses of the chemotherapy, the patient is disease free. The GA lesions also began to disappear following the institution of the chemotherapy and the lesions were mostly gone after a second course of ABVD.