Foreign Body Granulomatous Reaction Research Articles

HERNIA MESH EXPLANTATION FOR MESH INGUINODYNIA AND ALLODYNIA. WHY IS HERNIA MESH SO PAINFUL?

Abstract Introduction Chronic pain after mesh repair for abdominal wall hernia is an indication for the removal of mesh and reconstruction by a non-mesh technique. Materials and Methods In a consecutive series over 19 years, 128 patients had mesh removed to relieve chronic pain. This open method of mesh removal relies on confirming normal anatomical landmarks. The superior and inferior leaf of the External oblique aponeurosis are raised, the spermatic cord is identified and retracted. The mesh is gently dissected off the Internal oblique from lateral to medial, taking care in preserving the vas, and accompanying vessels. Adherent ilio-inguinal, iliohypogastric and genitofemoral nerves are removed with the mesh. The resultant recurrent hernia is repaired by Moloney darn, a tension-free tissue repair. Results 128 consecutive patients have been treated by mesh explantation and immediate reconstruction on average 6 years after implantation. Resolution of symptoms was experienced very shortly after the mesh removed. Preperitoneal mesh particularly Kugel patch has been the most difficult to remove. Meshes have been submitted for histological examination and the findings are usually chronic granulomatous foreign body reaction. Few complications have been encountered with a follow-up period ranging from 6 months to 15 years, the most common being the failure of explantation to alleviate inguinal pain in the long-term. Conclusion All hernia patients should be afforded informed consent including discussing the potential long-term consequences of chronic groin and abdominal pain.

A Severe Case of Pan-Facial Vitamin C Serum-Induced Foreign Body Granulomatous Reaction.

A Severe Case of Pan-Facial Vitamin C Serum-Induced Foreign Body Granulomatous Reaction.

Complex Hypersensitivity and Irritation Reaction (CHAIR) Phenomenon after Cyanoacrylate Closure of Varicose Vein.

Cyanoacrylate glue is a non-thermal, non-tumescent agent used to treat saphenous reflux. It was introduced to overcome heat-related discomfort and complications. Multiple randomized controlled trials using this therapy have demonstrated excellent clinical outcomes at long-term follow-up. However, diffuse injection-site inflammation and systemic urticaria are worrisome complications. In preclinical studies, serial histopathological findings demonstrated acute inflammatory reaction, subacute vasculitis, chronic granulomatous foreign body reaction, fibrotic changes with partial vascular recanalization, and chronic foreign body-type inflammatory response. While the exact nature of this unique complication remains undefined, complex hypersensitivity and irritation reaction phenomena have been suggested based on reported clinical presentations. The incidence of this complication has been reported as ranging from 0.3%-25.4%. Typically, erythematous reactions can occur near treatment sites, with symptoms ranging from mild pruritus and/or erythema that resolves without treatment to recurrent severe inflammation and pruritus requiring nonsteroidal anti-inflammatory drugs, antihistamines, and/or corticosteroids. Surgical excision has been rarely reported in patients with severe intractable inflammation or treatment-site infections. Although several anecdotal studies reported on using antihistaminics or corticosteroids, no effective strategies have been established to prevent this complication.

Thoughts and Concepts in Ultrasonography-guided Hyaluronidase Injection Technique.

INTRODUCTION The number of people receiving facial filler injections for aesthetic purpose has been increasing in recent years. Simultaneously, the number of patients dissolving fillers due to unsatisfactory outcomes or adverse effects, such as granuloma and allergy, is also increasing. Hyaluronidase has various uses, including dissolving hyaluronic acid fillers and treating granulomatous foreign body reactions and necrosis associated with filler injections.1 Here, I will discuss why ultrasonography should be performed before a filler dissolving injection and why the filler should be dissolved while viewing ultrasonographic images.2 Hyaluronidase is an endoglycosidase that breaks down hyaluronic acid into monosaccharides by cleaving its glycosidic bonds.3,4 Safe performance of this method requires sufficient understanding of the anatomy of the face, because of the heavy distribution of vital blood vessels, nerves, retaining ligaments, and muscles.5 The author performed filler removal using ultrasonography on more than 500 patients. First, palpation was performed, and after confirming the exact location and depth with ultrasound, it was marked with a pen. The filler was removed by injection of hyaluronidase. Some people had swelling and heat due to allergy to hyaluronidase, but they improved within 2–3 days and did not experience any other side effects (Fig. 1). This ultrasonography-guided hyaluronidase injection technique offers several advantages, as follows:Fig 1.: Pre- and post-procedure ultrasonic images. A, Filler in the anterior cheek shown before hyaluronidase injection. B, Anterior cheek after the filler has been completely dissolved. Ultrasonography is rapid and simple, with no risk of radiation exposure. This technique involves no additional discomfort for patients and can be more comfortable. This method does not require injection into a wide area around the injected filler, indicating that a smaller amount of hyaluronidase can be used. Vital blood vessels and nerves can be avoided using ultrasonographic images. When catastrophic adverse effects (such as blindness or necrosis) occur, exacerbation of such adverse effects can be quickly and accurately prevented. This method can effectively dissolve the filler, as the target is accurately set beforehand. In cases wherein undissolved fillers are still present despite several dissolution procedures, ultrasonography-guided hyaluronidase injection before removing the filler by incision is a feasible approach for both the patient and the physician. A limitation is that it is very difficult to completely remove granuloma or filler if it remains in a very small size, or if the filler is broken into very small sizes by melting it. In addition, there are cases in which the filler cannot be confirmed by ultrasound. The use of more precise ultrasound is necessary. This study is a conceptual thought and represents the author’s opinion based on experience, and a more scientific study with 500 patients will be conducted in the future. DISCLOSURE The author has no financial interest to declare in relation to the content of this article.

A rapidly-growing erythematous nodule on the right upper neck

A rapidly-growing erythematous nodule on the right upper neck

Infraorbital mass long after dermal filler injection: A report of two cases.

Hyaluronic acid fillers have been increasingly used throughout the world in the management of aging skin in the periocular region and other areas. To evaluate very late-term orbital mass formation secondary to Hyaluronic acid filler injection into the inferior eyelid. We report two cases that presented with a subcutaneous palpable mass localized at the right medial lower infraorbital area. Following clinical and radiological examination, surgical excision was required for the differential diagnosis of tumor. After pathologic examination and the finding of a foreign-body granulomatous reaction, both patients recalled that hyaluronic acid filler had once been injected into their lower eyelids approximately 10 years prior. This is consistent with the fact that dermal-filler-related granuloma formation may occur even years later in the differential diagnosis of mass lesions. It is suggested that patients be informed about the possible but rare mass effect in the infraorbital region. Clinicians should also attend to delayed hypersensitivity reactions, since patients may not recall details due to the length of time since injection.

Novel management of granuloma formation secondary to dermal filler: A multi-modality approach.

Dermal fillers for soft tissue augmentation have become increasingly popular among patients of all ages and ethnicities. With more widespread use, there has been an increased incidence of adverse reactions, one of which is the granulomatous foreign body reaction (GFBR). We present a three patient case series in which GFBR secondary to dermal filler was successfully treated with a multi-leveled approach. The first modality involves intralesional injection of a mixture containing 1cc of 5-fluorouracil (5-FU), 0.5cc of dexamethasone sodium phosphate, and 0.1cc of triamcinolone 10. The lesion is injected intradermally in small aliquots, similar to scar treatment. The patient then takes colchicine 1.2mg loading dose on day 1, then 0.6mg twice per day for 4 days concurrently with naproxen 500 mg orally once daily for 5-7 days. This process may be repeated in 6 weeks if the lesions have not resolved and PDL laser may be employed for residual post-inflammatory erythema. All three patients presented in this case series had significant aesthetic improvement in their dermal filler-derived foreign body granulomatous reactions. GFBR provides both a medical and aesthetic issue for these patients including mental distress, pain, and dysfunction, therefore having an effective treatment for GFBR will affect medical management of these patients, improving patient outcomes and satisfaction. Our proposed regimen for GFBR has been shown to be highly efficacious and safe for these patients, providing a significant improvement in both function and cosmesis of the area.

35320 Pilot evaluation of safety and efficacy in diverse skin types of a novel topical hyaluronidase-polysaccharide formulation for contour irregularities following filler injection

Injectable hyaluronidase is used off-label for skin contour irregularities, nodules or ischemia following hyaluronic acid (HA) fillers, and sometimes for non-HA filler nodules. However, hyaluronidase injections are associated with local allergic reactions (incidence 0.05-0.69% rising to 31.3% with 200,000 IU) and rare urticaria and angioedema (incidence < 0.1%). Availability and use of injectable hyaluronidase are limited by country-specific regulations, Some patients decline injections to address filler complications. After ethical board approval, 17 females aged 23 to 54 (six having skin phototypes IV-VI) with chronic post-filler contour irregularities received 1 to 3 topical treatments with a new formulation of hyaluronidase enzymatically complexed with botanical polysaccharides. Treated areas were infraorbital (10), lips (5), and malar festoons (2). Post-application massage was performed in office and at home. Two to 4 weeks after final treatment, physician-assessed contour improvement was 8-10/10 for 7 patients, 5-7/10 for 6, 1-4/10 for 3, and 0/10 for 1 patient. Fifteen patients evaluated their skin as more uniform (5/10 to 10/10). Satisfaction scores were 7-10/10 for 13 patients, 6/10 for 2, and 0-1/10 for 2. All evaluated treatment as Comfortable to Extremely Comfortable. The topical hyaluronidase-polysaccharide formulation has regulatory classification as a cosmetic. Based on this pilot evaluation, it may be of value in countries that prohibit injectable hyaluronidase, and for patients who decline injections. Larger, controlled studies will raise the evidence level for safety, efficacy and tolerability. It may be appropriate to evaluate nonaesthetic applications including granulomatous foreign body reactions and adjunctive acceleration of subcutaneous drug absorption and dispersion.

Efficacy of hyperthermia pleurodesis: A comparative experimental study on serous membrane of abdominopelvic and thoracic cavities of rats

BackgroundPleurodesis is a common technique for treating the accumulation of air or liquid in the pleural space caused by pneumothorax or pleural effusion, it is based on the bounding of pleural layers through induced inflammatory lesions. There are several pleurodesis procedures. ObjectivesTo test and describe the inflammatory effect of hyperthermia on the pleural and peritoneal mesothelia of rats, with the aim of testing the effectiveness of this process for inducing pleurodesis. Methods35 Sprague-Dawley (male/female) rats were randomized into four treatment groups: Group A (Talc, 10 individuals); group B (control, 5 individuals); group C (hyperthermic isotonic saline, 10 individuals); and group D (filtrate air at 50°, 10 individuals). Inflammatory effect of hyperthermia was the primary outcome parameter. ResultsIn the talc group, minimal adhesions between both pleural and peritoneal layers were observed in seven rats. Talc produced peritoneal mesothelium inflammation and fibrosis associated to foreign body giant cells in 80% (8/10) of the sample. Furthermore, clear evidence of a granulomatous foreign-body reaction was detected. No macroscopic and/or microscopic damage was registered in the remaining three groups (control, hyperthermic, and filtrate air). ConclusionsTalc is an excellent method for producing pleuro-peritoneal inflammatory lesions. On the contrary, hyperthermia apparently does not induce the macroscopic and microscopic damage that is required for efficient pleurodesis. Therefore, hyperthermia should not be used for pleurodesis procedures.

Preliminary application of native Nephila edulis spider silk and fibrin implant causes granulomatous foreign body reaction in vivo in rat’s spinal cord

After spinal cord injury, gliomesenchymal scaring inhibits axonal regeneration as a physical barrier. In peripheral nerve injuries, native spider silk was shown to be an effective scaffold to facilitate axonal re-growth and nerve regeneration. This study tested a two-composite scaffold made of longitudinally oriented native spider silk containing a Haemocomplettan fibrin sheath to bridge lesions in the spinal cord and enhance axonal sprouting. In vitro cultivation of neuronal cells on spider silk and fibrin revealed no cytotoxicity of the scaffold components. When spinal cord tissue was cultured on spider silk that was reeled around a metal frame, migration of different cell types, including neurons and neural stem cells, was observed. The scaffold was implanted into spinal cord lesions of four Wistar rats to evaluate the physical stress caused on the animals and examine the bridging potential for axonal sprouting and spinal cord regeneration. However, the implantation in-vivo resulted in a granulomatous foreign body reaction. Spider silk might be responsible for the strong immune response. Thus, the immune response to native spider silk seems to be stronger in the central nervous system than it is known to be in the peripheral body complicating the application of native spider silk in spinal cord injury treatment.

Pathological examination of blended and co-electrospinning hybrid polycaprolactone/polyurethane nanofibers for soft tissue engineering applications

The main objective of soft tissue engineering (STE) is to improve the quality of life by replacing damaged tissues with synthetic scaffolds. Collagen is the key structural protein of the native extracellular matrix with nano-scale diameter. Accordingly, this study focused on the fabrication of the blended and co-electrospinning hybrid synthetic polycaprolactone/polyurethane (PCL/PU) nanofibers scaffolds and investigates their in-vivo biocompatibility for the development of their clinical applications in STE. The body reactions were evaluated by examination of the edema, foreign body granulomatous reaction, granulation tissue formation, inflammation, calcification, fibroblastic change, and necrosis as the most important healing effects in pathology examination. The blended and co-electrospinning PCL/PU structures were successfully carried out in the nano-scale range without any beads. According to the histopathological examination of PCL, the scant, mild and mild to moderate, and acute and chronic have been reported for edema, foreign body granulomatous reaction, and inflammation, respectively. Also, severe (for edema), moderate (for foreign body granulomatous reaction), and mild to moderate chronic (for inflammation) were observed for PU. In blended PCL/PU nanofibers, decreasing of the edema and foreign body granulomatous reaction and increasing of the granulation tissue formation and inflammation were observed with the increasing composite ratio of PCL from 25 to 75%. Also in the co-electrospinning hybrid PCL/PU nanofibers, increasing edema, granulation tissue formation, and inflammation were observed by increasing the composite ratio of PU from 25 to 75%. Present study suggested that blended hybrid PCL75/PU25 nanofibers are a promising candidate as synthetic nanofibers scaffolds for STE applications.

Application of Hyaluronic Acid as a Biopolymer Material in Reconstruction of Interdental Papilla in Rats

Applying hyaluronic acid, a biopolymer material, in the treatment of interdental papilla reconstruction has become a trend. The main objective of this research is to investigate the histologic effect of hyaluronic acid on interdental papilla over time. Deficient interdental papilla models were surgically created in sixty-two Sprague-Dawley (SD) rats and were randomly treated with the injection of hyaluronic acid (HA group) or phosphate-buffered saline (sham control group) or left untreated (control group). After 2, 4, and 8 weeks, the rats were sacrificed in batches to observe the histological changes. A fluorochrome label was used to monitor bone formation in 8 weeks. Immunohistochemical analyses were performed to evaluate the expression of potentially relevant cytokines, vascular endothelial growth factor (VEGF), bone morphogenetic protein-2 (BMP-2), and Wnt-induced secreted protein 1 (WISP1) in the gingival tissue in 8 weeks. A preliminary study of HA degradation after 24 weeks was performed in two rats. Following the HA injection, no inflammation or granulomatous foreign body reaction was observed. HA was able to promote collagen fiber and alveolar bone regular formation in the reconstruction site. HA also enhanced VEGF, BMP-2, and WISP-1 expression in gingival tissue (p＜0.05). After 24 weeks, there was no HA filler observed in the interdental papilla. In conclusion, our study suggested that HA is an effective way to reconstruct deficient interdental papilla.

The “spade sign” as a pathognomonic histopathologic feature of acne keloidalis: Analysis of 33 cases of cicatricial alopecia

To the Editor: Historically, the specific diagnosis of cicatricial alopecia using histology alone has remained elusive or impossible.1Mirmirani P. Willey A. Headington J.T. Stenn K. McCalmont T.H. Price V.H. Primary cicatricial alopecia: histopathologic findings do not distinguish clinical variants.J Am Acad Dermatol. 2005; 52: 637-643Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar Acne keloidalis (AK) is a form of primary cicatricial alopecia, characterized by a mixed (lymphocytic and neutrophilic) infiltrate centered in the follicular isthmus. With time, there is thinning of the isthmic follicular epithelium and, eventually, clinically keloidal scarring associated with a foreign body granulomatous reaction, that is secondary to follicular destruction. Patients with AK exhibit features overlapping with other forms of alopecia.2Olsen E.A. Bergfeld W.F. Cotsarelis G. et al.Summary of North American Hair Research Society (NAHRS)-sponsored workshop on cicatricial alopecia, Duke University Medical Center, February 10 and 11, 2001.J Am Acad Dermatol. 2003; 48: 103-110Abstract Full Text Full Text PDF PubMed Scopus (291) Google Scholar In their recent AK series, Cheng et al3Cheng A.Y. Lee C.N. Hsieh F.N. et al.“Spade sign” and inflammation/fibrosis limited to the upper and mid-dermis as the pathognomonic features of acne keloidalis.J Dermatol. 2020; 47: 41-46Crossref PubMed Scopus (3) Google Scholar proposed that the spade sign (SS) is a pathognomonic histopathologic feature. They defined the SS as a spade-shaped space (resembling the spade symbol in playing cards) created by the dilated and thinned follicular epithelium in the lower isthmus. They also coined the term “balloon sign” (BS) as a variant, identical to SS, except for its round shape. The required presence of trichilemmal keratinization is characterized by the presence of isthmic follicular keratinocytes with pale eosinophilic cytoplasm and by abrupt keratinization, forming compact eosinophilic orthokeratin. To evaluate the sensitivity and specificity of the SS in a clinically relevant differential diagnosis, we performed a case control study to search for the SS in a spectrum of clinically confirmed cases of cicatricial alopecia from the teaching files of the senior author (Dr Fung). The vertical sections of hematoxylin-eosin–stained specimens were analyzed for the presence of the SS or BS. Thirty-three specimens from different patients were assessed. The diagnoses included AK (9 patients), folliculitis decalvans (6 patients), central centrifugal cicatricial alopecia (4 patients), dissecting cellulitis (4 patients), lichen planopilaris (6 patients), frontal fibrosing alopecia (2 patients), traction alopecia (1 patient), and discoid lupus (1 patient). The SS was found in 3 (3/9, 33%) AK specimens (Fig 1). Two specimens had the SS and BS in different affected follicles, whereas the third case had only the SS. The SS or BS was not present in the other cases. Upon comparing AK with all other forms of cicatricial alopecia, the sensitivity and specificity of the SS or BS for AK was found to be 33% and 100%, respectively. A single structure in 1 case of frontal fibrosing alopecia was classified as “pseudo-SS.” Although the follicular epithelium was dilated and thinned, it was located superficially and contained basket-weave orthokeratin. This superficial milia-type plugging, containing basophilic orthokeratin, may be seen in patients with frontal fibrosing alopecia and should not be confused with the SS (Fig 2).Fig 2Pseudospade sign or pseudo-balloon sign in a case of frontal fibrosing alopecia. The more superficial location of this structure is associated with epidermal keratinization in its superior portion, including a granular layer and loose, basophilic orthokeratin content, as is characteristic of comedones, milia, and epidermal inclusion cysts. (Original magnification: ×100).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Our study suggests that the SS or BS is a highly specific feature of AK. Cheng et al3Cheng A.Y. Lee C.N. Hsieh F.N. et al.“Spade sign” and inflammation/fibrosis limited to the upper and mid-dermis as the pathognomonic features of acne keloidalis.J Dermatol. 2020; 47: 41-46Crossref PubMed Scopus (3) Google Scholar also identified the SS or BS in exactly 33% (5/15) of their cases. The low sensitivity of the SS may reflect the fact that the SS or BS may only be appreciated during subacute AK, prior to follicular destruction. Although we have tended to regard AK and folliculitis decalvans as very similar histologically, we did not encounter SS in our folliculitis decalvans cases. Whether this represents an artifact of insufficient numbers of cases or a true difference in diagnostic specificity warrants further study. Our source of cases may represent a limitation because the teaching cases might have been biased toward more representative features than randomly selected cases. In summary, our findings support the fact that the SS is a highly specific or pathognomonic histopathologic feature of AK. Although the absence of the SS does not argue against AK, the presence of the SS supports its diagnosis. None disclosed. The authors thank Dr María Rashidi Springall, PhD, for assistance with the statistical analysis.

Pneumopathie granulomateuse induite par l’inhalation de Kayexalate® sous immunothérapie: Un diagnostic différentiel de progression tumorale et de toxicité pulmonaire spécifique des inhibiteurs de checkpoints immunitaires

When a patient treated by immune checkpoint inhibitors for metastatic melanoma presents with pulmonary symptoms, several diagnoses are possible. We report a case of acute granulomatous lung disease secondary to repeated kayexalate inhalations, and probably stimulated by immunotherapy. A patient treated with pembrolizumab and then ipilimumab presented with fever and acute shortness of breath. His pulmonary symptoms got progressively worse, leading to an acute respiratory distress syndrome. Chest CT displayed a pattern of non-specific organized pneumonia. Pulmonary infection, tumor progression, specific immune-related lung toxicity and immunotherapy-induced sarcoidosis were discussed. Histopathological examination of a lung biopsy showed a foreign body granulomatous macrophage reaction associated with crystalline, basophilic, purple and laminated elements, evoking kayexalate particles. These elements helped rewrite the diagnosis and confirmed a kayexalate-induced granulomatous lung disease secondary to repeated aspiration. The patient's respiratory condition got better following discontinuation of kayexalate together with systemic corticosteroids. Symptoms relapsed with resumption of the immunotherapy but were controlled with the addition of a new course of prolonged systemic corticosteroid therapy. We can hypothesize that immunotherapy played a role in the recurrence of the granulomatous lung reaction, or that there was an association between an aspiration pneumonia and an immunotherapy-induced lung toxicity. Facing respiratory symptoms during immunotherapy, the treatment may be the cause, but lung biopsy should be performed rapidly to arrive to a certain diagnosis.

Efficacy of hyperthermia pleurodesis: A comparative experimental study on serous membrane of abdominopelvic and thoracic cavities of rats

BackgroundPleurodesis is a common technique for treating the accumulation of air or liquid in the pleural space caused by pneumothorax or pleural effusion, it is based on the bounding of pleural layers through induced inflammatory lesions. There are several pleurodesis procedures. ObjectivesTo test and describe the inflammatory effect of hyperthermia on the pleural and peritoneal mesothelia of rats, with the aim of testing the effectiveness of this process for inducing pleurodesis. Methods35 Sprague-Dawley (male/female) rats were randomized into four treatment groups: Group A (Talc, 10 individuals); group B (control, 5 individuals); group C (hyperthermic isotonic saline, 10 individuals); and group D (filtrate air at 50°, 10 individuals). Inflammatory effect of hyperthermia was the primary outcome parameter. ResultsIn the talc group, minimal adhesions between both pleural and peritoneal layers were observed in seven rats. Talc produced peritoneal mesothelium inflammation and fibrosis associated to foreign body giant cells in 80% (8/10) of the sample. Furthermore, clear evidence of a granulomatous foreign-body reaction was detected. No macroscopic and/or microscopic damage was registered in the remaining three groups (control, hyperthermic, and filtrate air). ConclusionsTalc is an excellent method for producing pleuro-peritoneal inflammatory lesions. On the contrary, hyperthermia apparently does not induce the macroscopic and microscopic damage that is required for efficient pleurodesis. Therefore, hyperthermia should not be used for pleurodesis procedures.

Ki67/MART1 and p63/SOX10 Dual Immunohistochemistry Allows a Correct Interpretation of the Melanocytic Component in the Diagnosis of Pigmented Pilomatricoma.

Pilomatricoma is a relatively common benign cutaneous adnexal tumor and a well-recognized entity, while its pigmented variant is far less common and less reported. Its estimated frequency ranges from 11 to 24%, according to a limited number of published case series. This article describes the case of a 42-year-old man presenting a firm subcutaneous nodule of the periareolar region. Histopathologic examination revealed a cystic lesion composed of matrical and supramatrical cells accompanied by a foreign body granulomatous cell reaction. Interestingly, a hyperpigmented area with numerous hyperplastic melanocytes and few mitoses was detectable. In order to assess the cell lineage of the mitotically active component in the hyperpigmented area, double immunohistochemistry with Ki67/Mart1 and p63/SOX10 was performed. Pigmented pilomatricoma is an underrecognized, underreported variant, and double immunohistochemistry stain is an effective tool in providing the correct interpretation of the proliferative activity in the different cellular populations.

Foreign body granuloma reaction after endovascular therapy of an unruptured right frontal arteriovenous malformation.

Foreign body reactions after endovascular procedures for brain arteriovenous malformations are extremely rare. We report the case of a cerebral foreign body granuloma reaction after embolization of a frontal arteriovenous malformation with Onyx. A previously treated 36-year-old man underwent re-embolization of a residual and recurrent unruptured right frontal vascular malformation with Onyx. The post-procedural imaging revealed a right frontotemporal heterogeneously enhancing expansive lesion associated with a residual malformation. Following microsurgical resection, the histopathological examination of the expansive lesion revealed basophilic foreign body like deposits adjacent to multi-nucleated giant cells, highly compatible with cerebral foreign body granulomas reaction to Onyx. The clinical and radiological follow-up of the patient was favorable after complete resection of the lesions.

Diatoms: A novel cause of granulomatous inflammation of the head and neck

We report the first 4 cases of intraoral nonnecrotizing granulomatous foreign body reactions to diatoms, plausibly as a result of exogenous material introduced following iatrogenic or traumatic injury. Clinical and histopathologic findings of 4 intraoral cases of nonnecrotizing granulomatous foreign body reaction to diatoms, single-celled algae belonging to the taxonomic phylum Bacillariophyta, are reported. The lesions presented either in the jaws or in the soft tissue overlying the alveolar bone, in some instances mimicking an inflammatory lesion of odontogenic etiology. Microscopically, the lesions presented as nonnecrotizing granulomatous inflammation associated with either spherical and radially symmetric or rectangular and bilaterally symmetric diatomaceous foreign material. The diagnosis of a diatom-associated foreign body reaction necessitates familiarization with the histopathologic features of these organisms to accurately characterize the nature of such lesions.

Vulval acne: a case series describing clinical features and management.

Intermittent inflammation of the vulval pilosebaceous units is common and usually self-limiting, but some patients experience recurrent and more troublesome symptoms. There is a scarcity of information on this problem. We describe the clinical and histological features in these patients and the response to treatment. A retrospective, observational study of 16 patients with this phenomenon of recurrent, protracted folliculocentric inflammation of the vulval pilosebaceous unit was performed. Details on the clinical features, histology and response to treatment were collected. Mean age at presentation was 32years (range 21-45). All patients reported recurrent painful papules and pustules on the labia majora and labia minora. Nine patients reported a cyclical pattern to the development of lesions, with premenstrual exacerbation being most common. Histological examination of these lesions showed a folliculocentric microabscess formation surrounded by an acute and chronic inflammatory cell infiltrate, with a focal foreign-body granulomatous reaction. All our patients responded well to tetracycline, antiandrogenic or retinoid therapy. We propose the term 'vulval acne' for this condition and propose a stepwise approach to its management. We hope to highlight this as a common but underreported entity.

Clinico-pathological spectrum of cutaneous sarcoidosis: an experience from a government institute in North India.

Background and aimsSarcoidosis is a multisystem granulomatous disease of unknown etiology and cutaneous involvement is the second most frequent manifestation in systemic sarcoidosis.The aim of the present study is to evaluate the clinical and pathological spectrum of cutaneous sarcoidosis and compare the same with literature available.MethodsThe present retrospective study was conducted from January 2010–March 2015 and fifteen cases diagnosed as cutaneous sarcoidosis on biopsy were reviewed. The histological spectrum of cutaneous sarcoidosis was evaluated.ResultsThe mean age at diagnosis was 46 years. Nine (60%) cases out of 15 were females. Most common cutaneous lesions were nodules (46.6%) followed by papules (40%). Classically, lymphocyte-poor, non-caseating epithelioid cell granulomas, was the most common histologic finding. Inclusion bodies were seen in 20% cases with occasional presence of fibrinoid necrosis (13.3%). Peri-adnexal granuloma, seen in one case, raised the possibility of tuberculoid leprosy. Foreign body was seen in one case supporting the opinion that sarcoidosis and granulomatous foreign body reaction are not mutually exclusive. Epidermal changes including atrophy, loss of rete pegs, acanthosis, papillomatosis, hyperkeratosis, parakeratosis and basal cell vacuolation were seen in 46.6% cases. Reticulin was positive in all the cases while special stains for acid fast bacilli and fungi were negative.ConclusionThe clinical presentation of cutaneous sarcoidosis may be variable. Presence of naked, reticulin-rich granulomas is the most characteristic histopathological finding. Correlation of clinical history with histologic examination is essential to exclude other granulomatous diseases including leprosy, syphilis, other infectious granulomatous diseases and foreign body reaction.