Vasculitis in granuloma annulare: histopathology and direct immunofluorescence

Granuloma annulare and possible relation to purified protein derivative administration: a case report

BACKGROUND

Granuloma annulare is a noninfectious inflammatory granulomatous skin disease characterized by an erythematous or skin colored annulare plaque. The diagnosis of granuloma annulare may be challenging owing to its diverse morphology. In such cases, a correlation between the clinical findings and histologic findings are necessary.

CASE PRESENTATION

We report a case of granuloma annulare after purified protein derivative administration. A 56-year-old Caucasian female patient complained of mildly pruritic rashes which started on both arms and lower extremities, and eventually spread to both thighs, the left popliteal region, left upper back, and the right abdominal area. About 6 weeks prior to the eruption of the rashes, the patient had been given a purified protein derivative tuberculin skin test. Biopsy specimens revealed dermal histiocytes palisading around areas of mucin and degenerated collagen, confirming granuloma annulare. After treatment with 0.1% topical triamcinolone acetanide and 500 mg oral metronidazole, the patient's lesions resolved.

DISCUSSION

Relatively little is known about granuloma annulare's exact etiology. Granuloma annulare has four variations presenting as either localized, generalized, subcutaneous, or perforating and patch granuloma annulare. The clinical prognosis for granuloma annulare varies according to clinical subtypes. Proposed causal mechanisms of subcutaneous granuloma annulare include physical trauma, infections, immunizations, insect bites, diabetes mellitus, and alterations in the cell-mediated immune responses. The disease likely has an inflammatory component. Clinically, granuloma annulare may be confused with many other skin diseases.

CONCLUSION

This case of subcutaneous granuloma annulare was reported since it is a rare dermatologic pathological condition that can be confused with other skin rash disorders. Although it is a benign self-limited disease, definitive diagnosis is important to rule out other pathologies with similar clinical appearances, such as cancer or human immunodeficiency virus (HIV) infection. Diagnostic confirmation is best made through skin biopsy.

The epifascial cap: A typical imaging sign for subcutaneous granuloma annulare in children

OBJECTIVES

Subcutaneous granuloma annulare (SGA) is a rare, self-limiting granulomatous disease in children, commonly diagnosed by histopathology following biopsy or surgical excision. This study aimed to identify imaging clues for SGA that could expedite accurate diagnosis and avoid the need for biopsy in children.

METHODS

We retrospectively analyzed complete hospital records of all children diagnosed with SGA at our institution from January 2001 to December 2020. Detailed disease history, imaging findings, management, and outcome were evaluated.

RESULTS

We identified 28 patients (20 girls) at a median age of 3.75 (range 1-12.5 years). Ten patients presented with multiple lesions. Most lesions were located on the lower extremities (n = 26/41). Ultrasound examinations were performed on all patients, and 12 (43%) patients also received an MRI. Surgical intervention was conducted in 18 (64%) patients either by incisional biopsy (n = 6) or total excision of the lump (n = 12). In all patients who did not undergo surgery, SGA resolved spontaneously. A careful review of the MRIs led to the discovery of a characteristic imaging shape of SGA lesions: the epifascial cap with a typical broad circular base laying on the fascia, extending towards the subdermal/dermal tissue. This distinctive shape was evident in every patient in our cohort.

CONCLUSIONS

The "Epifascial Cap Sign" is a specific imaging sign for SGA, which to the best of our knowledge, helps distinguish this disease from other subcutaneous lesions. Recognition of this novel diagnostic sign combined with the historical and physical findings should enable clinicians to establish SGA diagnosis easily and diminish the need for further invasive diagnostic procedures.

Histopathologic Aspects of Malignancy-Associated Granuloma Annulare: A Single Institution Experience

Granuloma annulare (GA) is a benign, self-limiting granulomatous inflammatory disease that exhibits different histologic patterns. Infrequently, granuloma annulare can be associated with malignancy, the so-called malignancy-associated granuloma annulare (MGA). In this study, we aimed to compare the clinical and histopathological differences between GA and MGA. We retrospectively reviewed patient charts and identified 35 patients diagnosed with GA and concurrent hematological or solid organ malignancies as a case group. Additionally, we identified 33 patients without any known solid organ or hematological malignancy as a control group. MGA is commonly seen in the seventh decade of life, while GA affects the younger population. MGA is most commonly presented in the extremities of the body. The most common malignancy associated with MGA was chronic lymphocytic leukemia. Prostate cancer was the most common type of solid organ malignancy that was associated with MGA. The most common histopathological pattern seen in MGA was interstitial, comprising half of the cases. Multinucleated giant cells were present in half of the MGA cases and in most of the control group. In the literature, there are no established features that distinguish MGA from GA. Although MGA and GA have overlapping features, in our series, we found that the interstitial pattern was more common in MGA, while the necrobiotic pattern was more common in GA.

Non-Infectious Granulomatous Dermatoses: A Pathologist's Perspective

Granulomatous dermatitis (GD) is one of the commonest tissue reaction patterns encountered in dermatopathology practice. Granulomatous inflammation in the skin can be seen in a wide range of conditions, thus, granulomatous dermatitis always poses significant challenge even to the astute dermatologists and dermatopathologists. Broadly, granulomatous dermatitis is divided into two groups-infectious and non-infectious, the prevalence of both highly variable and show overlapping pathology. However, there are subtle histological clues, which when combined with clinical features, help to narrow down the differential diagnosis. Thus, a good Clinicopathological correlation (CPC) along with histochemical stains, culture and ancillary techniques including molecular studies are required for arriving at a definite diagnosis. In this review, we shall discuss the histological clues to diagnose non-infectious granulomatous dermatitis (NIGD) and their differential diagnoses.

Association of Granuloma Annulare With Type 2 Diabetes, Hyperlipidemia, Autoimmune Disorders, and Hematologic Malignant Neoplasms

IMPORTANCE

Although granuloma annulare (GA) has been associated with several other conditions, these studies have been limited by single-center designs and small sample sizes.

OBJECTIVE

To evaluate whether there is an association between GA and type 2 diabetes, hyperlipidemia, autoimmune conditions, and hematologic malignant neoplasms, using a large population-based cohort study.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study conducted between January 1, 2016, and June 30, 2019, used deidentified data from the US Optum Clinformatics Data Mart Database. A total of 5137 patients with GA were matched by age and sex with up to 10 randomly selected controls (n = 51 169) with a diagnosis of a nevus or seborrheic keratosis.

MAIN OUTCOMES AND MEASURES

Logistic regression was used to evaluate for potential associations between GA and diabetes, hyperlipidemia, autoimmune conditions, and hematologic malignant neoplasms. All analyses were adjusted for race/ethnicity, income, and educational level.

RESULTS

This study included 5137 individuals with GA (3760 women [73.2%]; mean [SD] age, 57.7 [19.0] years) and 51 169 controls (37 456 women [73.2%]; mean [SD] age, 57.7 [19.0] years). Those with GA were more likely than controls to have baseline diabetes (1086 [21.1%] vs 6780 [13.3%]; adjusted odds ratio [aOR], 1.67; 95% CI, 1.55-1.80), hyperlipidemia (1669 [32.5%] vs 14 553 [28.4%]; aOR, 1.15; 95% CI, 1.08-1.23), hypothyroidism (727 [14.2%] vs 5780 [11.3%]; aOR, 1.24; 95% CI, 1.15-1.36), and rheumatoid arthritis (62 [1.2%] vs 441 [0.9%]; aOR, 1.34; 95% CI, 1.02-1.75). Those with GA were more likely to have incident diabetes (144 [2.8%] vs 1061 [2.1%]; aOR, 1.31; 95% CI, 1.10-1.57), hypothyroidism (41 [0.8%] vs 252 [0.5%]; aOR, 1.59; 95% CI, 1.14-2.22), systemic lupus erythematosus (21 [0.4%] vs 65 [0.1%]; aOR, 3.06; 95% CI, 1.86-5.01), and rheumatoid arthritis (26 [0.5%] vs 122 [0.2%]; aOR, 2.05; 95% CI, 1.34-3.13). There was no association between GA and an increased risk of hematologic malignant neoplasms.

CONCLUSIONS AND RELEVANCE

This population-based cohort study identified associations between GA and baseline diabetes and hyperlipidemia as well as between GA and both baseline and incident autoimmune conditions. These findings suggest that diabetes and hyperlipidemia may be risk factors for the development of GA and that autoimmunity may be an important factor in the pathogenesis of GA.

Clinical and pathological changes in the skin with granuloma annulare

Granuloma annulare (GA) is a dermatosis of unknown etiology, which has distinctive clinical and histological features. In this article, we present current information about the etiology, pathogenesis, clinical picture and pathomorphological signs of GA, as well as conduct differential diagnosis of GA with diseases that have a similar clinical and histological picture.

[Granulomatous reaction pattern of the skin : Interstitial granulomatous dermatitis - lymphoma - vasculitis]

A particular diagnostic situation in the classification of a granulomatous dermatitis results when no circumscribed granulomas but instead a diffuse interstitial histiocytic inflammatory infiltrate, a granulomatous vasculitis or a neoplastic lymphocytic infiltrate is found. Interstitial granulomatous dermatitis was originally described in patients with arthritis. Later, it was recognized that there are also associations with other usually immunological diseases. Differentiating between interstitial granulomatous dermatitis and the interstitial form of granuloma annulare, early morphea and variants of borreliosis or scleromyxedema as well as interstitial granulomatous drug reaction can be very difficult. In long-standing cutaneous granulomatous infiltrates, T‑cell lymphoma should be excluded. Occasionally only a small number of atypical lymphocytes can be found. The detection of a monoclonal T‑cell expansion is then particularly helpful. Only recently, a CD8-positive granulomatous cutaneous T‑cell lymphoma was described which occurred in patients with immunodeficiencies. A granulomatous vasculitis in the skin is extremely rare. According to the Chapel Hill classification from 2012, systemic granulomatous vasculitis is equated with giant cell arteritis. Extracutaneous large arteries are involved. On rare occasions, involvement of the temporal artery can result in skin necrosis. More commonly granulomatous infiltrates in combination with vasculitis can be observed, whereby various infectious diseases, sarcoidosis and nodular vasculitis should be considered. Granulomatosis with polyangiitis (formerly Wegener's granulomatosis), presents in the skin as leukocytoclastic vasculitis. Here granulomas are extremely rare.

Giant Cell Arteritis with Generalized Granuloma Annulare

We report the case of an 80-year-old man with generalized granuloma annulare (GGA) who subsequently developed giant cell arteritis (GCA). Steroid treatment was effective for both diseases in this case. Although cases of concomitant GGA and GCA have rarely been reported, previous studies suggest that common histological characteristics underlie the two diseases. It is therefore necessary to recognize that GGA can be complicated by GCA, particularly when typical symptoms, such as headache and visual disturbance, are present.

Case for diagnosis. Patch granuloma annulare

A 59-year-old woman reported a 20-day history of slightly scaly erythematous infiltrated patches on her palms and soles with a histopathological result which was consistent with interstitial-pattern granuloma annulare, clinically classified as patch granuloma annulare. This is a rare clinical variant of granuloma annulare, with an unknown incidence and characteristic clinical and histopathological features. The patient evolved with a complete remission of the lesions after biopsy and the use of high-potency topical corticosteroid.

Spontaneous and antiviral-induced cutaneous lesions in chronic hepatitis B virus infection

AIM

To describe spontaneous, or interferon (IFN)- or immunization-induced skin lesions in hepatitis B virus (HBV) infection.

METHODS

A comprehensive literature search of all the papers presenting case reports of dermatological lesions in patients with chronic HBV infection was carried out. We included only patients with histologically proven skin lesions that appeared in the normal course of hepatitis B infection, or after immunization for hepatitis B or antiviral treatment.

RESULTS

We found 44 papers on this topic, reporting 151 cases. About 2% of patients with hepatitis B infection, mainly men, presented with skin lesions. Among patients with chronic hepatitis B, vasculitis and essential mixed cryoglobulinemia seemed to be the most frequent skin lesion (53.3%), followed by papular changes, rashes and Gianotti-Crosti syndrome, skin carcinoma and Henoch-Schönlein purpura were rare. IFN treatment seemed to be effective against HBV-associated and immunoglobulin-complex-mediated disease (vasculitis). Two cutaneous lesions (lichen planus and granuloma annulare) were described after hepatitis B vaccination. Systemic lupus and lupus-like lesions were the most frequently encountered lesions after antiviral treatment. Immunosuppressive and steroid therapy ameliorates lichen planus lesions in 50% of cases.

CONCLUSION

Vasculitis was the most frequent spontaneous skin lesion found in chronic hepatitis B. Lichen planus was most frequent after immunization and lupus/lupus-like lesions after IFN.

Granuloma annularis revealing Wegener's granulomatosis

Skin manifestations are often associated with systemic autoimmune diseases (SAD). Some SAD, such as systemic lupus erythematosus, psoriatic arthritis and scleroderma display pathognomonic dermatological features, whereas other systemic diseases such as sarcoidosis, vasculitis and rheumatoid arthritis can present with non-specific skin manifestations that range from erythema nodosum to necrotic lesions. Here we report the case of a 25-year-old man with uveitis, polyarthrirtis, pulmonary involvement, nephrotic syndrome, cutaneous granuloma and pneumonia by E. coli.

Clinical and pathological features of generalized granuloma annulare with their correlation: a retrospective multicenter study in Korea

BACKGROUND

Generalized granuloma annulare (GGA) is a benign skin disorder of an unknown etiology. Though some cases of GGA have been reported, few systemic reviews of the clinical and pathological features of GGA have been performed.

OBJECTIVE

The purpose of this study is to analyze and correlate the clinical and pathological characteristics of GGA in Korean patients.

METHODS

We conducted a retrospective study that included 54 biopsy specimens of Korean GGA patients, and the clinical and pathological features of GGA were reviewed and analyzed for their correlation.

RESULTS

The cutaneous lesions could be divided into the annular (24, 44%) and nonannular types (30, 56%), and the lesions were more common in males than in females (29 males and 25 females). The incidence of GGA showed a bimodal age distribution. The number of patients who presented within the first decade was 24 cases (44%), and 24 cases (44%) were over the fifth decade. Eight patients (15%) had systemic diseases. Especially, diabetes mellitus (DM) occurred only in the adult GGA patients over forty years old. The pathological findings showed dermal granulomatous lesions that consisted of either a palisading pattern (28, 52%) or an interstitial pattern (26, 48%).

CONCLUSION

In contrast to the previously reported studies, the age of GGA onset showed a bimodal distribution, and GGA was observed more often in males. The prevalence of DM in the GGA affected individuals was higher than that found in the general Korean population. Therefore, it is recommended to perform a work-up for DM in the GGA affected patients who are over forty years old.

Collagen-elastic tissue changes and vascular involvement in granuloma annulare: a review of 35 cases

BACKGROUND

The pathogenesis of granuloma annulare (GA) is unclear. Collagen fiber degeneration is commonly reported, and there are several conflicting studies on elastic fiber and vascular changes associated with GA. In this study, we aimed to evaluate histopathologic characteristics, collagen and elastic tissue changes and vascular changes in GA.

METHODS

Clinical records of 35 GA patients were examined alongside serial sections of 38 biopsy specimens from these patients. New sections of biopsy tissue were stained with hematoxylin and eosin, Verhoeff-van Gieson or Alcian blue and then evaluated.

RESULTS

Four different histopathologic patterns were observed: interstitial (57.9%), palisadic granulomatous (26.3%), sarcoidal granulomatous (5.3%) and mixed (10.5%). Dermal mucin deposition was determined in 84.2% of specimens. Solar elastosis was observed in only seven specimens, and elastophagocytosis was observed in only two specimens. Collagen and elastic tissue damages were consistent findings in all biopsy specimens. Fibrin thrombi and vasculitic changes were not found in any of the specimens from this patient group.

CONCLUSIONS

Elastic and collagen fiber damage are the main accompanying features of GA, which may develop from delayed-type hypersensitivity. Vasculitis does not appear to be a major causative process. Sun exposure also seems to have no major effect on the formation of GA but can be one of the stimulants or predisposing factors.

Subcutaneous Granuloma Annulare

Subcutaneous granuloma annulare is a rare clinicopathologic variant of granuloma annulare, characterized by subcutaneous nodules that may appear alone or in association with intradermal lesions. The pathogenesis of this deep variant of granuloma annulare remains uncertain. Subcutaneous granuloma annulare appears more frequently in children and young adults, and the lesions consist of subcutaneous nodules with no inflammatory appearance at the skin surface, most commonly located on the anterior aspects of the lower legs, hands, head, and buttocks. Usually, subcutaneous granuloma annulare is an authentic and exclusive panniculitic process with no dermal participation, although in 25% of the patients lesions of subcutaneous granuloma annulare coexist with the classic findings of granuloma annulare in the dermis. Histopathologically, subcutaneous granuloma annulare consist of areas of basophilic degeneration of collagen bundles with peripheral palisading granulomas involving the connective tissue septa of the subcutis. Usually, the area of necrobiosis in subcutaneous granuloma annulare is larger than in the dermal counterpart. The central necrobiotic areas contain increased amounts of connective tissue mucin and nuclear dust from neutrophils between the degenerated collagen bundles. Eosinophils are more common in subcutaneous granuloma annulare than in the dermal counterpart. There are not descriptions of subcutaneous granuloma annulare showing a histopathologic pattern of the so-called incomplete or interstitial variant. Histopathologic differential diagnosis of subcutaneous granuloma annulare includes rheumatoid nodule, necrobiosis lipoidica and epithelioid sarcoma.

Granuloma anular: distribuição tecidual dos dendrócitos dérmicos fator XIIIa+, das células dérmicas trombomodulina+ e de macrófagos CD68+

FUNDAMENTOS: Um subgrupo de células dérmicas relacionado a macrófagos expressa o fator pró-coagulante XIIIa enquanto outro subgrupo expressa o co-fator anticoagulante trombomodulina. Esses tipos celulares podem estar envolvidos em eventos de inflamação e reparo tecidual. OBJETIVOS: Investigar a participação de células dérmicas fator XIIIa+ e de células dérmicas trombomodulina+ (TM) no quadro histopatológico do granuloma anular que se caracteriza por necrobiose do colágeno e presença de infiltrado de macrófagos. MATERIAIS E MÉTODOS: O quadro histopatológico do granuloma anular observado em 23 fragmentos da pele obtida pela biópsia foi classificado de acordo com a presença de degeneração completa ou incompleta do colágeno e distribuição do infiltrado inflamatório. Dendrócitos dérmicos fator XIIIa+ e células dérmicas trombomodulina+ foram reconhecidos por meio de anticorpos próprios aplicados em protocolos de imuno-histoquímica; um marcador para macrófagos (CD68) também foi utilizado. Observou-se a distribuição dos subtipos celulares distintos, bem como realizou-se análise semiquantitativa. RESULTADOS: Dendrócitos fator XIIIa+ foram escassamente detectados, enquanto células trombomodulina+ e CD68+ representaram considerável proporção do infiltrado celular, observadas na posição periférica (arranjo em paliçada), entre fibras colágenas degeneradas ou mesmo difusamente distribuídas. Houve tendência de associação da semiquantificação alta de células trombomodulina+ com a semiquantificação baixa de dendrócitos fator XIIIa+ e com o tipo histológico II. Hiperplasia de dendrócitos dérmicos ao redor da lesão foi observada. CONCLUSÃO: A diferente distribuição tecidual de células fator XIIIa+ e TM+ pode refletir suas participações distintas e complementares no reparo do tecido dérmico e no processo evolutivo da lesão no granuloma anular.

The granuloma annulare phenotype and tuberculosis

At one time it was believed that granuloma annulare was associated with or even caused by tuberculosis. In the past 50 years, that idea has seemed to be of little more than historic importance. A case is reported of chronic, inadequately treated tuberculosis with erythema induratum in which clinical and histologic lesions compatible with granuloma annulare occurred. Specific antituberculosis therapy caused clearing of the skin lesions. The previous reported cases of granuloma annulare and tuberculosis are summarized. Other systemic diseases reportedly associated with granuloma annulare are noted to emphasize the many possible etiologic relationships. Granuloma annulare may be viewed not as a disease sui generis but as a phenotypic macrophage-granulomatous response to multiple etiologic disease patterns.

Patch granuloma annulare: clinicopathologic study of 6 patients

BACKGROUND

Granuloma annulare is a common skin disorder that usually presents with smooth papules arranged as annular plaques. Variants, such as disseminated, subcutaneous, and perforating granuloma annulare, have been described.

OBJECTIVE

The purpose of this study is to describe the clinical and histologic features of a distinct patch form of granuloma annulare.

METHODS

The clinical and histologic features of 6 patients with patch granuloma annulare were evaluated.

RESULTS

Six women 27 to 72 years of age had patches on the extremities. Two patients also had a lesion on the trunk. Only one patient had annular patches. Histologic examination showed an interstitial infiltrate of lymphocytes and histiocytes with diffuse necrobiosis.

CONCLUSION

Patch granuloma annulare is a distinct variant with rather subtle clinical and histologic features. A high index of suspicion both clinically and histologically aids in making the diagnosis.

Granuloma annulare in herpes zoster scars

A 54-year-old Japanese female developed granuloma annulare twice in herpes zoster scars. Soon after the second event, she developed ulcerative colitis, which was well controlled by sulfonamides and corticosteroid suppository. She had no history of diabetes mellitus. There was no recurrence of granuloma annulare by June of 1999. Granuloma annulare might have contributed to the complications of ulcerative colitis, although this had not been noticed before.

Generalised granuloma annulare successfully treated with PUVA

Disseminated granuloma annulare is an uncommon disorder in which both topical and systemic therapy may have limited success. Anecdotal reports have suggested that PUVA may result in complete clearance of disease; however, maintenance PUVA therapy has usually been required in order to maintain remission. We report the successful treatment of a patient with 5-methoxypsoralen over a 7-month period who remained in remission during a 20-month follow up period.

Cutaneous extravascular necrotizing granuloma (Winkelmann granuloma): confirmation of the association with systemic disease

BACKGROUND

An unusual palisading granuloma has been described in patients with immunoreactive diseases. Multiple names have been given to this lesion.

OBJECTIVE

Our aim was to verify whether a distinct palisading granuloma can be used as a marker for systemic disease. We also propose unifying nomenclature.

METHODS

Thirty-four biopsy specimens from 22 patients were selected for study on the basis of histologic criteria. The medical histories of these patients were subsequently reviewed for clinical information.

RESULTS

At least 21 of the 22 patients with cutaneous extravascular necrotizing granuloma had evidence of an underlying immunoreactive systemic illness. In each, the systemic disease preceded or was diagnosed concurrently with the cutaneous lesions.

CONCLUSION

The cutaneous extravascular necrotizing granuloma has unique clinical and histologic features. In a great majority of cases, a systemic immunoreactive disease is present.

Association of generalized granuloma annulare with autoantibodies

Granuloma annulare is a degenerative disease of the skin histopathologically characterized by focal degeneration of collagen with a surrounding infiltrate of lymphoid cells, histiocytic cells, and multinucleated giant cells. Immunological abnormalities such as delayed-type hypersensitivity and vasculitic origin are suspected in the pathogenesis. We describe three patients with generalized granuloma annulare, in whom autoantibodies, including antinuclear antibody, antithyroid stimulating hormone receptor antibody, and immune complex, were detected.

Rheumatoid papules: a report on four patients with histopathologic analysis

BACKGROUND

The rheumatoid papule is a recently described skin manifestation of rheumatoid arthritis.

OBJECTIVE

Rheumatoid papules from four patients with classic rheumatoid arthritis were examined to determine the origin of this palisading granulomatous reaction.

METHODS

Immunofluorescence and electron microscopic studies were performed on biopsy specimens of rheumatoid papules.

RESULTS

Leukocytoclastic vasculitis with collagen alteration and lymphohistiocytic infiltration were observed. The immunofluorescence study revealed deposits of immunoglobulins and complement in the vessel walls and in the area of collagen alteration. Electron microscopy revealed epithelioid cell-like histiocytes among altered collagen fibers. These cells contained abundant lysosomes and were connected to neighboring cells by well-developed intricate processes.

CONCLUSION

Vasculitis is important in the pathogenesis of rheumatoid papules. In patients with rheumatoid papules, systemic evaluation should be performed because these are a manifestation of rheumatoid vasculitis.

Granuloma annulare of the buccal mucosa in association with AIDS

This case report describes the occurrence of a lesion of granuloma annulare in the buccal mucosa. This skin condition occurs rarely on the mucous membranes and has not been previously described in the oral cavity. It was initially seen as a raised, firm lesion with a 1-month history in a 31-year-old patient with acquired immune deficiency.

Bilateral idiopathic inflammation of the optic nerve sheaths. Light and electron microscopic findings

Idiopathic perioptic neuritis is a term used to describe noninfectious inflammatory disorders of the optic nerve sheaths, the causes of which are unknown. In the following report, a 68-year-old woman with bilateral visual loss was found to have chronic inflammation with necrobiotic granulomas of her optic nerve sheaths. The patient, who had no systemic condition known to be associated with necrobiotic granuloma, lost vision from infarction of the optic nerve parenchyma and from compression due to thickened meninges. Although there are similarities between the inflammatory reaction in this case to the necrobiotic dermatoses, the pathogenesis of this condition remains obscure.

Rheumatoid papules: lesions showing features of vasculitis and palisading granuloma

Whether palisading granuloma formation occurs with leukocytoclastic vasculitis in rheumatoid nodules and in histopathologically similar conditions is debatable. Patients with high titers for rheumatoid factor and severe erosive rheumatoid arthritis are at risk for both rheumatoid vasculitis and rheumatoid nodules. A patient with all of these features developed a papular eruption. These papules showed clinicopathologic features both of leukocytoclastic vasculitis and of early palisading granuloma. Lesions resolved slowly with low-dose oral corticosteroid therapy. It is proposed that these lesions be called rheumatoid papules and that they may represent a link between vasculitis and the palisaded granulomatous reaction seen in rheumatoid nodules.

Granuloma annulare in patients with human immunodeficiency virus infections

We present four cases of granuloma annulare occurring in patients with human immunodeficiency virus (HIV) infection. These patients had either an extensive localized form or generalized granuloma annulare. The patient with generalized granuloma annulare was clinically reminiscent of the previously described papular eruption seen in HIV-positive patients. In several patients with the localized form, Kaposi's sarcoma was considered in the differential diagnosis. In all patients, however, the eruptions were surprisingly transient. The similarity of the localized form of granuloma annulare to Kaposi's sarcoma and the generalized micropapular form to the papular eruption of acquired immunodeficiency syndrome seen in HIV-positive patients illustrates the usefulness of skin biopsies in these patients.

Generalized granuloma annulare: histopathology and immunopathology. Systematic review of 100 cases and comparison with localized granuloma annulare

Some form of collagen alteration (necrobiosis) was observed in 53% of patients with generalized granuloma annulare and in 79% of patients with localized granuloma annulare. Fragmentation of collagen bundles was the most common single type of collagen abnormality in both groups. Collagen sclerosis, accompanied by a strong palisading pattern of histiocytes, was more frequent in localized granuloma annulare. Results of microdroplet lipid staining were positive in 80% of annulare cases and 39.3% of nonannulare cases of generalized granuloma annulare. Inflammatory cells were confined to peripheral perivascular lymphocytes; bandlike granuloma below the epidermis was observed. Positive results of direct immunofluorescence tests in 12 of 23 patients with generalized granuloma annulare suggested that fibrin deposition in areas of altered collagen is less frequent in the generalized than in the localized form, a possible reflection of the lower rate of histologic collagen alteration in that group. Lymphohistiocytic granuloma with various degrees of collagen degeneration, microdroplet lipid accumulation, and mucin deposition form the basic pathologic description of granuloma annulare.

Granuloma annulare arising in herpes zoster scars. Report of two cases and review of the literature

We present two patients who developed granuloma annulare in the scars from previous herpes zoster. The development of granuloma annulare in herpes zoster scars may represent an atypical delayed hypersensitivity immune reaction to herpes zoster/varicella virus antigen(s) or a tissue antigen altered by the virus.

Sulfone treatment of granuloma annulare

Although spontaneous remission of granuloma annulare is not uncommon, most cases are chronic and resistant to a variety of therapeutic modalities. In our study we confirm the beneficial effect of dapsone treatment in patients with localized or generalized granuloma annulare. The results indicate that dapsone is a useful drug to control or at least to improve skin lesions in the majority of patients.

Differential staining pattern of lysozyme in palisading granulomas: an immunoperoxidase study

Biopsies from palisading granulomas of granuloma annulare, necrobiosis lipoidica, and rheumatoid nodules were examined for the presence of lysozyme (muramidase). This enzyme was identified in paraffin-embedded tissues using a primary antibody to lysozyme and the peroxidase-antiperoxidase technic. Some inflammatory cells in the infiltrate of granuloma annulare stained abundantly for lysozyme, whereas those of necrobiosis lipoidica and rheumatoid nodule stained minimally and negatively, respectively. This pattern of staining may be of diagnostic value and suggests that the histiocytoid cells constituting the infiltrate of granuloma annulare are in some way different from the similar-appearing cells of necrobiosis lipoidica and rheumatoid nodule.

Granuloma annulare

Granuloma annular (GA) is a benign inflammatory skin disease usually localized to the distal extremities, although generalized, perforating, and subcutaneous variants have also been identified. A regular histopathologic feature is the presence of mononuclear cells, often in palisading array, around foci of altered collagen. The clinical and histologic features of each subtype of GA are discussed along with a differential diagnosis. A variety of remedies have been used to treat GA, but efficacy is hard to define in a disease in which spontaneous resolution is usual outcome. GA has not been conclusively linked either to diabetes or solar radiation. Recent data suggest a role for vascular injury or delayed-type hypersensitivity in the pathogenesis, but the cause of GA remains obscure.