Variant Of Granuloma Annulare Research Articles

Granuloma annulare subtypes: sonographic features and clinicopathological correlation.

Diagnosis of granuloma annulare (GA) is based on the clinical and histopathological findings. However, only sporadic case reports of subcutaneous GA sonography have been published to date. The objective of this study was to evaluate the ultrasonographic patterns of the different clinical variants of GA: localized, generalized, subcutaneous, and perforating. In this retrospective observational study, we analyzed and correlated the clinical, histopathological, and sonographic features of 15 patients diagnosed with GA. We included 8 women and 7 men with a mean age of 48.4years (8-77years). We found three different sonographic patterns depending on the clinical variant of GA: poorly defined hypoechoic band including the dermis (dermal pattern), irregularly shaped hypoechoic hypodermal lumps (hypodermal pattern), and ill-defined hypoechoic dermal and subcutaneous lesions (mixed pattern). Five cases showed increased blood flow signal on Doppler interrogation. Although our findings are broadly consistent with the previous reports of subcutaneous GA, the sonographic features in localized, generalized, and perforating GA have not been previously reported.

Patch-type granuloma annulare: An institution-based study of 23 cases.

Granuloma annulare (GA) is a skin disorder of uncertain etiology. Patch (type) GA is an uncommon variant of GA with a paucity of data characterizing it. We describe the features of 23 cases of patch GA. The archives of dermatopathology were searched for cases of patch GA. The clinical history and morphology for each patient were reviewed. Only cases with patch clinical morphology were included. The clinical and histopathologic features were assessed including the pattern of granulomatous inflammation and presence of other inflammatory cell types. Most patients were female (19/23) with erythematous patches on the trunk and proximal extremities. The most common clinical differential diagnosis included mycosis fungoides (MF), morphea and contact dermatitis. Dyslipidemia was the most common comorbidity (30%), followed by diabetes (15%) and hypertension (15%). Histopathologic features included interstitial lymphocytes and histiocytes with dermal mucin. Two cases showed focal palisaded granulomas. Eosinophils and plasma cells were present in 1/3 of cases. Patch GA is an uncommon GA variant with an interstitial granulomatous histopathologic pattern that predominantly affects women over 50. It can mimic interstitial MF and early morphea both clinically and histopathologically. Awareness of this GA variant can help prevent misdiagnosis and inappropriate treatment for these patients.

A Case of Acute-Onset, Painful Acral Granuloma Annulare.

Dear Editor: Acute-onset, painful acral granuloma annulare (GA), a rare variant first described by Brey et al.1 in 2006, is characterized by sudden onset of painful lesions on the hands and feet, and scattered lesions at other sites. Patients may have associated arthralgia, diarrhea, and fever. The erythrocyte sedimentation rate (ESR) may be elevated1. A 57-year-old woman presented with painful lesions on the hands and legs 4 months ago. The lesions abruptly began as small erythematous plaques and slightly enlarged after beginning. The patient experienced febrile sensations, myalgia, and back pain a month before developing the lesions. Intermittent treatment of oral prednisolone from a local clinic alleviated her back pain, but new cutaneous lesions persistently develop. Physical examination revealed tender, erythematous, annular plaques on the palms, lateral sides of the fingers, and the legs (Fig. 1). Initial laboratory examination by a rheumatologist revealed an elevated ESR of 52 with otherwise unremarkable findings for rheumatoid factor, anti-neutrophilic cytoplasmic antibody, anti-cardiolipin antibody and thyroid function test. Biopsy specimen from the left second finger revealed a palisade of histiocytes surrounding degenerated collagen and mucin in the dermis (Fig. 2A, B). Alcian blue (pH 2.5) staining highlighted mucin in the center of the granuloma (Fig. 2C). Based on the clinical and histological findings, acute-onset, painful acral GA was diagnosed. Fig. 1 Tender erythematous annular plaques on the lateral side of second and third finger. Fig. 2 (A) Palisade of histiocytes surrounding degenerated collagen and mucin in the dermis. A broad zone of mucinous degenerated collagen fibers with infiltrating lymphohistiocytic granuloma (H&E, ×100). (B) (H&E, ×400). (C) ... Although the occurrence of GA on the dorsum of the hands is frequent, the involvement of the palms appears to be very rare2,3,4,5. Generally, GA is characterized by asymptomatic or mildly pruritic lesions, but GA on the palms manifests variable clinical presentations, including painful or pruritic papules and plaques2,3,4. Acute-onset, painful acral GA also manifests unusual painful lesions similar to GA lesions on the palms. However, the former shows constitutional symptoms in addition to skin lesions, which may raise suspicion about an autoimmune disease. Therefore, unnecessary examinations and treatments may be performed and final diagnosis may be delayed. Brey et al.1 reported 2 of 4 patients presenting with arthralgia, which increased authors' concern that the disease might represent an early manifestation of an autoimmune disease. However, extensive serologic and radiologic examinations for autoimmune diseases were negative. Our patient was initially also evaluated by a rheumatologist, but all serologic findings for autoimmune diseases were unremarkable except for an elevated ESR. From this clinical viewpoint, we assume that acute-onset, painful acral GA could be classified as a distinct variant of GA distinguishing it from GA on the palms. Acute-onset painful acral GA should be differentiated from conditions including Sweet's syndrome, interstitial granulomatous dermatitis with arthritis, palisaded neutrophilic and granulomatous dermatitis, and rheumatoid nodule, which may present similar clinical presentations like painful papules or plaques and constitutional symptoms1. Herein, we report a very rare and interesting case of acute-onset, painful acral GA. Clinicians should be aware of the atypical clinical presentation of GA such as painful and/or tender acral eruptions with constitutional symptoms. To classify acute-onset, painful acral GA as a variant of GA, more reports of cases are needed.

Generalized granuloma annulare in a folliculocentric distribution

We present a 69-year-old man with type 2 diabetes mellitus and a five-year history of an eruption of follicular pustules, papules, and nodules, which was identified histopathologically as folliculocentric granuloma annulare (GA). Folliculocentric generalized GA is a rarely reported variant of GA, in which the the palisading histiocytes form focal granulomas in a follicular pattern. In this case, the GA may represent an isotopic phenomenon, with lesions developing in hair follicles that were previously affected by a suppurative folliculitis.

Subcutaneous Granuloma Annulare of the Penis Associated with a Urethral Anomaly: Case Report and Review of the Literature

Granuloma annulare (GA) is an uncommon benign inflammatory skin condition, most often found on the extremities of young females. The subcutaneous variant of GA involving the penis is very rare. We report a case of subcutaneous GA associated with a urethral anomaly in a 15-year-old boy that persisted for a year. Treatment options are discussed with a review of the current literature.

Granuloma Annulare With Prominent Lymphoid Infiltrates (“Pseudolymphomatous” Granuloma Annulare)

Granuloma annulare (GA) is characterized histopathologically by 3 patterns: necrobiotic granuloma, interstitial incomplete form and, rarely, sarcoidal or tuberculoid granuloma. The amount of lymphoid infiltrate in GA is usually limited. We describe 10 cases of GA with prominent "pseudolymphomatous" lymphoid infiltrates mimicking cutaneous lymphoid hyperplasia. Patients were 6 males and 4 females (mean age 49.9 years, median age 47 years, age range 25-70). Lesions were localized to a limited area of the body (n = 6), or involved the entire trunk (n = 3), or were generalized (n = 1). The correct clinical diagnosis of GA was provided only in 30% of the cases. In all cases, histopathologic features were characterized by dense, nodular, superficial, and deep infiltrates of lymphocytes. Immunohistology revealed predominance of T lymphocytes in 7 of 7 tested cases. This "pseudolymphomatous" variant of GA represents a pitfall in the histopathologic diagnosis of the disease and may be misinterpreted as other types of cutaneous lymphoproliferative disorders.

Granuloma Annulare of the Penis: A Uncommon Location for an Usual Disease

The subcutaneous clinical variant of granuloma annulare (GA) is rare and tends to present more frequently in children, in locations unusual for conventional GA. Involvement of the penis is exceptional and has been rarely reported. Most cases are located in the shaft of the penis and tend to persist without spontaneous remission. Diagnosis is done only after biopsy, and surgical resection of the lesions is not unusual. We report a new case of subcutaneous GA of the penis in a 13-year-old boy with lesions persistent for the past year. Surgical excision of one of them allowed the correct diagnosis. No further treatment was done, and the condition has not remitted 1 year later. We stress the importance of clinical recognition of unusual presentations of GA to avoid overtreatment of lesions that do not need an aggressive approach.

Book Review: Rongioletti F, Smoller BR (eds.). Clinical and Pathological Aspects of Skin Diseases in Endocrine, Metabolic, Nutritional and Deposition Disease. New York: Springer; 2010

This is an ambitious undertaking, as suggested by the lengthy title, and the authors successfully cover endocrine, metabolic, nutritional, and deposition disorders. The book is all the more thorough as there is seamless assimilation of clinical, histologic, and radiologic information for these diseases. The aims are fulfilled with 1) concise text, 2) atlas-like inclusion of over 174 clinical photos and 116 histopathologic photomicrographs, 3) insight into the clinical appearance and course of disease, 4) detailed histopathologic descriptions, 5) therapeutic options, and 6) bulleted key points. This book should appeal to all dermatopathologists, as it is compact, richly illustrated, and easy to read. Some minor criticisms include a need for white balancing many of the histopathologic photomicrographs and for improvement of brightness and color of the clinical photographs. Despite this, the figures more than adequately depict the numerous diseases summarized in this book. In particular, some of the images not to be missed include beautiful clinical examples of necrobiosis lipoidica (Fig. 2.1), pretibial myxedema (plaque-type) (Fig. 3.2), acromegaly (Fig. 4.1), eruptive xanthoma (Fig. 6.4), fixed drug (Fig. 14.6), and primary systemic amyloidosis (Fig. 17.4). This atlas further delves into variants of granuloma annulare (chapter 2), pretibial myxedema (chapter 3), xanthomas (chapter 6), and mucinoses (chapter 18). While this is a strength, it also is a minor weakness, as the appetite is whetted to see even more images of rare variants like discrete papular lichen myxedematosus and pure nodular lichen myxedematosus. The authors are recognized experts in the subjects covered in this book, and even while achieving their broad aims, the authors include valuable pearls throughout the text. Some involve differentiating certain disorders: for example, acne secondary to hypercorticism lacks comedones and cysts (unlike acne vulgaris), siderosis around eccrine glands may be specific for idiopathic hemochromatosis, and the linear array of papules is a clue for scleromyxedema as opposed to scleredema or scleroderma. A treatment pearl is using the hyperpigmentation of Addison disease to monitor disease activity. As the authors’ expertise shines through with comprehensive coverage of the myriad diseases, it would be of value to know their opinion on issues like: Lichen myxedematosus – how frequently is it associated with paraproteinemia or other systemic findings [1]? Should all cases be screened and, if so, just once? Reticular erythematous mucinosis – the literature suggests many cases are associated with autoimmune disorders [2]. Is the author’s experience different? Calciphylaxis – how often is it not in the setting of renal failure [3, 4]? Is there a better prognosis if not truncal? Overall, this book succinctly achieves a wide-ranging look at endocrine, metabolic, nutritional, and deposition disease. Concise text accompanies numerous photographs and photomicrographs, enabling the reader to get a handle on these diseases clinically and histopathologically. This is a worthy read for anyone interested in these disorders.

Study of actinic granuloma annulare in a middle-aged woman

Granuloma annulare is a chronic, benign, self-limited inflammatory disease of the skin which displays dermal papules and plaques in an annular arrangement, usually localized to the distal extremities. However, several variants of granuloma annulare have been identified, including perforating, subcutaneous, generalized and actinic. Classic dermatopathologic findings of granuloma annulare include a foci of altered collagen surrounded by palisading histiocytes and multinucleated giant cells. In this case the clinical and histological features of a middle-aged woman with actinic granuloma annulare is described.

Mitotic granuloma annulare: a clinicopathologic study of 20 cases.

The finding of mitotic figures in granuloma annulare (GA) has not been emphasized in the literature. We describe 20 cases of a cellular, mitotically active variant of GA; we defined this group as cases having > or = 1 mitosis per 10 hpf. Clinically, the lesions could not be distinguished from typical, localized GA: there were 9 males and 11 females with a mean patient age of 49 +/- 15 years (mean +/- SD), compared to 45 +/- 20 years in a randomly selected control group of 60 patients with GA, and no unusual sites of predilection were noted. Histologically, a classic, palisading granuloma pattern predominated (18/20 cases). Lesions were located in the mid-dermis and tended to be more cellular than typical GA. The histiocytes comprising the lesion often had enlarged nuclei and prominent nucleoli. The number of mitoses per 10 hpf was 3.0 +/- 1.5 (range 1.0-7.2), control group 0.3 +/- 0.5; occasional atypical mitotic figures were observed. The proliferative nature of these lesions was confirmed using MIB-1 staining; the percentage of MIB-1 positive cells ranged from 5%-29% (mean 15 +/- 6%). Mitotic GA must be distinguished histologically from neoplastic processes, in particular epithelioid sarcoma. We conclude that histiocytes in clinically typical GA can exhibit an increased mitotic rate. Recognition of this variant is important in order to avoid overdiagnosis of a malignant condition.

Pseudorheumatoid Nodule (Deep Granuloma Annulare) of Childhood: Clinicopathologic Features of Twenty Patients

Pseudorheumatoid nodule of childhood is seen uncommonly by pathologists and is thought to be a variant of granuloma annulare. We report a series of 20 patients (13 M, 7 F) age 1 to 17 years. Fourteen lesions arose on the front of the lower limb, and 14 children had numerous lesions at diagnosis. Seven developed some form of recurrence, except for one case occurring at the site of the original lesion. Only one patient had a weakly positive rheumatoid factor, and was the patient with remote recurrence. As a significant number of lesions arose around the foot when the child was beginning to walk or starting to wear shoes, it is suggested that trauma plays a role in the development of some of these lesions.