Persistent Subcutaneous Nodules Research Articles

Persistent subcutaneous nodules and Aluminium sensitization: Literature review and Case series report

The development of persistent subcutaneous nodules at vaccination or hyposensitization injection site is a rare and under-reported event. These lesions have been attributed to the aluminium salts used as adjuvants. Patch testing on patients with the aforementioned clinical manifestations have yielded high sensitization rates to aluminium. It is believed this delayed hypersensitivity is the apparent cause of these reactive lesions in the dermis and subcutaneous tissue. In addition, aluminium hypersensitivity may cause contact dermatitis and gingivitis since it can be found in toothpaste and deodorants. We describe a series of 4 patients who developed SN at the injection site of vaccines and/or hyposensitization therapy, who underwent ultrasonography and patch testing for diagnostic confirmation. Patient management usually consists of potent topical steroids, antihistaminics, emollients and aluminium-containing products avoidance.

Occult Invasive Lobular Carcinoma Presenting as an Axillary Skin Metastatic Lesion Underwent Neoadjuvant Endocrine Therapy and Surgical Resection: A Case Report and Review of Literature

IntroductionInvasive lobular carcinoma (ILC) is the second most common type of breast cancer accounting for 5–15% of all breast cancer cases. It usually presents with nonspecific signs and symptoms. Occult breast cancer presenting as an axillary mass is rare, with prevalence of 0.3–1%, less likely with isolated cutaneous breast metastasis as a first presentation. There are limited data in the literature on patients who underwent endocrine therapy and complete surgical resection.Case PresentationA 54-year-old woman with left axillary skin swelling that had been persisting for 6 years was diagnosed with ILC 18 months ago presenting with an ulcerated axillary skin lesion and was managed with letrozole in another facility as she was estrogen receptor (ER) and progesterone receptor (PR) positive. She received letrozole for 18 months and had a partial response in the form of healing of the ulcer with persistent subcutaneous nodules. Her breast mammogram, ultrasound, and magnetic resonance imaging findings were unremarkable; however, there were few prominent left axillary lymph nodes. A biopsy of the left axillary lymph node was positive for malignancy, consistent with ILC. A skin punch biopsy of the axillary skin lesion showed ILC extending to the dermis with no background breast tissue. The patient underwent left modified radical mastectomy with excision of the left axillary skin lesion. The breast specimen comprised 0.4 mm of ILC as the primary malignancy and nine positive axillary lymph node malignancies. The patient received adjuvant radiotherapy and continued to receive letrozole. There were no signs of complications or recurrence during the follow-up period.ConclusionUlcerated skin lesions in the axilla should raise concerns regarding breast cancer metastasis. In cases of isolated cutaneous breast metastases, surgical excision can be considered in combination with endocrine therapy.

Subcutaneous Panniculitis-Like T-Cell Lymphoma in a Patient Receiving Long-Term Panniculitis Treatment: A Case Report

Subcutaneous panniculitis-like t-cell lymphoma (SPTL) is known as a rare type of cutaneous lymphoma characterized with penetration of neoplastic T cells to the subcutaneous tissue. It constituates less than 1% of all non-Hodgkin lymphomas. We described herein a 49-year-old woman with SPTL who presented with red-purple-colored persistent subcutaneous nodules disseminated on trunk and both extremities. The lesions were present for 15 years. She had been diagnosed as panniculitis and her lesions had not regressed with panniculitis treatment. SPTL was diagnosed due to histopathological examination of the lesions that revealed CD3 positive, CD8 positive, CD4 negative and CD56 negative atypical lymphoid infiltration with lobular and septal panniculitis-like pattern. SPTL must be always kept in mind as a differential diagnosis while examining biopsies of patients with panniculitis-like lesions resistant to long-term treatment. It is also important to remember that the biopsy material should be in such depth that involves subcutaneous fat tissue.

Local Vaccine Site Reactions and Contact Allergy to Aluminum

Childhood vaccines are a routine part of pediatric care in the United States; clinicians must be able to recognize and interpret associated localized adverse reactions. Redness and induration at the site of injection are commonly reported and are considered to be the result of local inflammation or hematoma formation, although other atypical reactions can occur. We report the case of a 6-month-old infant who developed subcutaneous nodules at the sites of his 4- and 6-month Pentacel (DTaP/Hib/IPV, diphtheria, tetanus, acellular pertussis, Haemophilus b conjugate, and inactivated poliovirus vaccine) and 6-month Prevnar (heptavalent pneumococcal vaccine) injections. Infectious disease and immunodeficiency examinations were unremarkable. Aluminum contact allergy was considered, and contact allergy testing confirmed sensitivity to aluminum. Although rare, aluminum contact allergy after routine immunization can occur and should be considered in the differential diagnosis of persistent subcutaneous nodules after vaccination.

Persistent subcutaneous nodules after immunotherapy injections for allergic asthma

Adverse effects of desensitization injections mostly consist of local transient reactions. Rarely, persistent subcutaneous nodular lesions may also develop at the site of injection. These reactions have been attributed to the vaccines containing aluminium hydroxide. Aluminium hydroxide is used as an adjuvant in vaccines and hyposensitization solutions. We describe a patient who presented persistent, itchy subcutaneous nodules as a local reaction to allergen immunotherapy for the treatment of allergic asthma.

There is an association between contact allergy to aluminium and persistent subcutaneous nodules in children undergoing hyposensitization therapy

The development of persistent itchy nodules at the injection site following hyposensitization therapy with aluminium-precipitated antigen extract has been described in several reports. Occasionally, contact allergy to aluminium has been reported in individuals with such nodules. To investigate if hyposensitization therapy can induce contact allergy to aluminium and examine if there is any association between persistent subcutaneous nodules and aluminium allergy. Sixty-one children with allergic asthma and/or allergic rhinitis participated in the study of whom 37 had had hyposensitization therapy. The study consisted of a non-clinical part based on a questionnaire and a clinical part with a physical examination, self-assessment of itching, and patch testing. To secure an unbiased evaluation of possible reactions, the investigators were blinded. Contact allergy to aluminium was found in eight participants, all in the exposed group (8/37 versus 0/24, P = 0.02). Examination showed nodules on the upper arms in 13 participants, all in the group exposed to hyposensitization therapy. Nodules were over-represented in patients with contact allergy to aluminium. There was a statistically significant association between contact allergy to aluminium and persistent subcutaneous nodules in children who had had hyposensitization therapy.

Mastzellreiches Aluminiumgranulom

Persistent subcutaneous nodules arise at the injection sites of aluminium hydroxide-absorbed hyposensitization solutions. We present a hitherto unreported phenomenon in aluminium granuloma. Two years after specific immunotherapy, a patient suffered increasingly from urticaria. Besides inflammatory infiltrates surrounding necrotic areas, microscopy of the specimen revealed numerous mast cells surrounding the necrotic tissue areas. The histological phenomenon of increased mast cell populations in aluminium granuloma might reflect the association with urticaria, which is probably more frequent than previously reported.

Pseudolymphome sous-cutané postvaccinal de survenue tardive

Persistent subcutaneous nodules arise on rare occasions at sites of injection of aluminium hydroxide-adsorbed vaccine. We report a case following a diphtheria, tetanus and pertussis vaccination. The late onset of the lesion, four years after the injection, led to an uncertain preoperative diagnosis. Histopathologic examination showed features of a subcutaneous pseudolymphoma. The demonstration of aluminium by Morin staining and atomic absorption spectrometry on a paraffin-embedded tissue probe supported the diagnosis of a vaccination-induced pseudolymphoma.

Nódulos subcutáneos persistentes por aluminio

Abstract—Persistent subcutaneous nodules are a rare manifestation of delayed hypersensitivity to aluminum. We present the case of a 17-year-old girl who presented with two painful nodules, in both arms, over the injection sites of desensitizing vaccines for the treatment of allergies to pine and acacia. We discuss the most significant aspects of this rare disease.

Genetic polymorphism and clinical outcome: identification of individuals at risk of a poor clinical outcome.

Susceptibility and outcome in complex disorders such as asthma and cancer appear to be determined, at least in part, by genetic polymorphism. However, while our ability to identify new allelic variants and study them in case and control populations has greatly improved, considerable difficulties remain in elucidating how many genes determine particular clinical phenotypes. This is because most studies have concentrated on study of single genes in relatively small study groups. The important issues of gene-gene interactions (epistasis) and high-risk subgroups have not yet been adequately addressed. We now describe a general approach, using patients with head and neck cancers as an example. Our purpose is to demonstrate candidate gene selection, statistical approaches, and identification of patient subgroups.

Persistent Subcutaneous Nodules in Patients Hyposensitized With Aluminum-Containing Allergen Extracts

The development of persistent nodules that cause pain and itching at a vaccination or hyposensitization injection site is a rare event. These lesions have been mainly attributed to a hypersensitivity reaction to aluminum hydroxide, which is used as an absorbing agent in many vaccines and hyposensitization preparations. Patch tests with standard antigens and aluminum compounds and histopathologic and ultrastructural studies were performed on 10 patients with persistent subcutaneous nodules on the upper part of their arms after injection of aluminum-adsorbed dust and/or pollen extracts. The nodules appeared 1 month to 6.5 years after injections. The results of patch tests with 2% aluminum chloride were positive in five patients. Histopathologic examination revealed two different patterns: some biopsy specimens (from lesions of less than 9 months' duration) showed a pure foreign body histiocytic reaction characterized by extracellular amorphous dermal basophilic deposits with a histiocytic-macrophagic reaction; others showed a delayed hypersensitivity granulomatous reaction in association with an histiocytic foreign body response. The lesions were characterized by a unifocal or multifocal unencapsulated granulomatous reaction in the deep dermis and/or subcutaneous tissue. Eosinophilic necrotic areas surrounded by dense fibrous bands and a massive inflammatory infiltrate (lymphoid follicles, large histiocytic cells, abundant eosinophils, and some plasma cells) were observed. A granular basophilic material in extracellular spaces and within the cytoplasm of some histiocytes was also noted. Electron microscopic studies revealed intracytoplasmic and extracellular deposits of a fibrillar electron-dense material. Persistent subcutaneous nodules that develop after the administration of aluminum-containing preparations may show two characteristic histopathologic patterns. A pure histiocytic foreign body reaction was observed in early lesions, and a delayed hypersensitivity granulomatous reaction was seen in older lesions. No relationship between histopathologic pattern and patch test results was observed. Aluminum-free preparations should be used in patients in whom these nodules develop.

Persistent subcutaneous nodules in patients hyposensitized with aluminum-containing allergen extracts

Persistent subcutaneous nodules in patients hyposensitized with aluminum-containing allergen extracts

Aluminium allergy in patients hyposensitized with aluminium‐precipitated antigen extracts

During hyposensitization therapy with aluminium-precipitated antigen solutions, a small % of patients develop persistent subcutaneous nodules at the injection site; the existence of delayed sensitivity to aluminium has been implicated in the pathogenesis of these nodules. We studied the prevalence of aluminium sensitivity (using patch, prick and intradermal tests) and common contact allergens (TRUE Test) in 20 healthy subjects, and in 40 patients treated with aluminium-containing extracts, 20 of whom had persistent subcutaneous nodules that remained for more than 2 months, the other half having no nodular reactions or nodules that remained for less than 2 months. Aluminium sensitivity was found only in those patients of the treated group who had persistent nodular reactions, 4 cases of positivity to an aluminium chloride patch test being found. All 4 cases were women, nodules remained for more than 6 months, and intracutaneous tests were negative. 3 of them also had contact sensitivity to nickel. In 2 cases, nodules were removed for histological and histochemical examination, showing non-specific inflammatory granulomas, and aluminium crystals being found in only 1 case. It is concluded that delayed sensitivity to aluminium appears to be implicated in the pathogenesis of persistent nodular reactions, but sensitivity to aluminium was not found in patients treated with aluminium-precipitated extracts without persistent nodular reactions.

耳下腺こう筋部に発生した石灰化上皮腫の２例

We presented two cases of calcifying epithelioma in the parotid-masseteric region. One was a 59-year-old woman, and the other was a 38-year-old man. Both cases had been aware of persistent subcutaneous nodules in the region for about thirty years. The nodules were painless, well-defined, movable and firm.A clinical diagnosis of calcifying epithelioma was made and the tumors were enucleated. There was minimal adherence between the tumors and the surrounding tissues. The enucleated tumors measured 28 × 17 × 7 mm and 20 × 13 × 7 mm, respectively.Histopathologically, they were composed of distinctly bordered nests or masses of shadow cells which possessed a central unstained area due to nuclear loss. Few basophilic cells and large areas of calcification were observed. In part of the tumors, a little bone formation was also observed.The postoperative progress of the two patients is satisfactory without recurrence.

Persistent subcutaneous nodules in children hyposensitized with aluminium-containing allergen extracts.

A follow-up study of 202 children who had received hyposensitization with aluminium-containing allergens showed that 1-3 years after cessation of hyposensitization 13 children still had severely pruiginous treatment-resistant subcutaneous nodules in their forearms. Because of their long persistence the nodules of six children were studied in detail. Histologically, the nodules showed infiltration with lymphocytes (forming germinal centres), macrophages, plasma cells, mast cells and a few eosinophils. In five patients aluminium crystals were found scattered between the cells and, in addition, the phagosomes of the macrophages contained aluminium. Patch tests for aluminium were positive in four of the six patients. It is concluded that persisting nodules during hyposensitization with aluminium-containing allergens may indicate development of aluminium hypersensitivity, and if this is confirmed hyposensitization should be discontinued.

Subcutaneous angiolymphoid hyperplasia with eosinophilia.

SUMMARY.— Persistent subcutaneous nodules on the head and neck with distinctive histological features of angiolymphoid hyperplasia with eosinophilia are reported in nine patients. They were all young adults and had one or more lesions ranging from 1 to 10 cm. in diameter. Apart from blood eosinophilia, there were no systemic manifestations. While some lesions persisted for several years, the condition appears to be benign. The nodules lie mainly in the sub-cutis but sometimes extend into the overlying dermis and deeply into muscle or fascia. They are composed of unencapsulated masses of angiolymphoid hyperplasia with the following components: 1. Exuberant proliferation of capillary vessels, often with imperfectly canalized masses of endothelium. 2. Massive infiltration with eosinophils and an excess of mast cells. 3. Reticulin formation but little collagenous fibrosis. 4. Lymphoreticular hyperplasia, increasing with the duration of the lesion and leading to lymphoid follicle formation in lesions of one year or more duration. The clinical and histological features suggest enough common ground for regarding subcutaneous angiolymphoid hyperplasia with eosinophilia as a distinct pathological entity. Its relation to Kimura's disease as described in Japan is discussed.