Foreign Body Granulomas

Pilonidal granuloma formation after an incision and drainage procedure is associated with retained hair within the sinus - A case series

INTRODUCTION AND IMPORTANCE

Pilonidal disease may present with a draining secondary sinus or granuloma, but the development of these findings is not well-characterized.

CASE PRESENTATION

Two adolescent males presented with pilonidal disease. The first patient had a gluteal cleft abscess, and an incision and drainage procedure was performed. Although the abscess resolved, the incision site formed a granuloma with intermittent draining wound with granulation tissue. He underwent a pit-picking procedure along with excision of the granuloma. A large amount of hair was also removed from within the pilonidal sinus. The second patient underwent an incision and drainage procedure to treat the pilonidal abscess. The incision site evolved into a granuloma with recurring drainage. A pit-picking procedure was performed, and the granuloma was excised. During the excision, a moderate amount of hair was evacuated from the pilonidal sinus.

CLINICAL DISCUSSION

Many pilonidal patients present with a granuloma or secondary sinus at the gluteal cleft, but there has been no documentation of the natural history of this development. The role of hair is central to pilonidal disease pathophysiology and is a known factor in foreign body granuloma formation - a cutaneous inflammatory response to endogenous or exogenous material in the dermis that is not broken down readily by macrophages.

CONCLUSION

Even though the pilonidal abscess was drained with an incision, a granuloma was able to form with recurrent drainage when hair was retained within the pilonidal sinus.

A Comprehensive Multi-drug Strategy for the Management of Foreign Body Granuloma Following Mesotherapy

BACKGROUND

Mesotherapy is a medical technique that administers cosmetic nutrients directly to the dermis through microdrop injections for aesthetic purposes. Its application has become increasingly widespread. However, there have also been a growing number of reported cases of multiple foreign body granulomas following mesotherapy. It is crucial to find an effective and safe treatment.

METHODS

In this study, 31 patients with facial foreign body granuloma after mesotherapy were included. A mixture of 5-fluorouracil, lidocaine injection , and normal saline was prepared in a ratio of 1:1:4 and injected subcutaneously. Triamcinolone acetonide, 5-fluorouracil, lidocaine injection, and normal saline were prepared in a ratio of 2:5:3:10. Subcutaneous injections were administered to each papule using a 34G needle. The treatments were scheduled at intervals of 10-14 days. Color Doppler ultrasound was used to evaluate the condition before the initial treatment and after the final treatment.

RESULTS

The preoperative ultrasonography revealed diffuse hypoechoic areas in the dermis of the facial skin. After an average of 2-4 treatment sessions, a significant improvement was observed in all patients' appearance, with reduced redness and swelling, softened nodules, absence of pain and itching symptoms, and no evident abnormal echo on ultrasound examination. During a follow-up period ranging from 1 to 8 months, no recurrence or adverse reactions were reported.

CONCLUSION

This technique demonstrates clear efficacy. And this formulation effectively reduces the dosage of triamcinolone acetonide and minimizes the risk of adverse reactions such as skin atrophy. Therefore, it can be considered an effective treatment for multiple foreign body granulomas following mesotherapy.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Incarcerated Ink: A Case of Mycobacterium chelonae

A 30-year-old African American male presented with pain and swelling of the right foot one month after receiving a tattoo on this foot in prison. During his admission for presumed cellulitis, he developed a rash on his contralateral (left) leg, which had been tattooed 10 months prior. A biopsy of the contralateral (left) leg showed acute, chronic, and granulomatous inflammation with a differential diagnosis including infection. His overall condition and both legs worsened, prompting biopsy and tissue culture of the right ankle and foot. Pathology of the right foot showed a granulomatous reaction. Culture grew Mycobacterium chelonae. This case highlights the importance of considering infectious etiologies for rashes appearing within tattoos and represents the importance of a full investigation to obtain the correct diagnosis.

Ultrasound features of benign paediatric lumps: radiology-pathology correlation

Ultrasonography is an appropriate first-line imaging technique for the characterisation of paediatric lumps, given its relative accessibility and absence of radiation exposure. Together with a thorough history and examination, ultrasonography can help to distinguish benign lesions from malignancy. It can also aid further characterisation of benign lesions to inform onward investigation and management. This review features the evaluation of common benign paediatric lumps together with their characteristic sonographic features, following correlation with histopathology results or clinical follow-up.

The Novel Use of Rare Earth Magnets for the Extraction of Metallic Soft Tissue Foreign Bodies in Children

INTRODUCTION

Metallic foreign bodies (mFB) are common following penetrating injuries in children. The mFB commonly occur in the head and neck region and extremity soft tissues. Removal may be indicated due to morbidity related to pain or migration. Extraction can be challenging to localize, often requiring wide exposure, and may be difficult to achieve in cosmetically sensitive areas. Different technological adjuncts have been used to facilitate foreign body removal including fluoroscopy, ultrasound, and more recently in adults, surgical magnets. The most powerful commercially available magnets are rare earth magnets comprised of neodymium iron and boron (Ndy). With the goal of reducing radiation exposure and the morbidity of mFB removal with associated soft tissue injury in children, a strategy was introduced utilizing Ndy to optimize extraction with minimal soft tissue surgical dissection.

MATERIALS AND METHODS

Two children with extremity mFB treated with Ndy between January 2021 and July 2021 were analyzed. We utilized commercially available ring type neodymium-iron-boron magnets with dimensions of 1 3/8-inch outer diameter x 1/8-inch inner diameter and 1/16 inch thick with a power of 13 200 gauss that were processed for use according to our hospital protocols. Our main clinical indication was for the detection and retrieval of small ferromagnetic foreign bodies embedded in superficial extremity soft tissues.

RESULTS

In the operating room under general anesthesia, the mFB were localized utilizing fluoroscopy. A 1.0 cm skin incision was made into the subdermal soft tissues overlying the area of the mFB. No surgical tissue dissection was performed. The mFB could not be visualized in the soft tissue. Using fluoroscopy to localize the mFB, the Ndy was then placed into the wound in close proximity to the mFB. The mFB were immediately magnetized to the Ndy and the mFB were extracted from the soft tissues without any further surgical dissection. Two simple interrupted nylon sutures were placed to close the incision. The total operative time was 2 and 2.5 minutes respectively. The children recovered uneventfully and are without complication.

CONCLUSIONS

The use of Ndy to remove extremity soft tissue mFB in children appears to be feasible, safe, and efficient. Use of the Ndy allowed extraction via a small incision, optimizing the aesthetic result and avoiding the need for cross-sectional imaging, extensive surgical dissection, tissue reconstruction and prolonged operative time or x-ray exposure. The development of magnets of increasing energy density may be indicated to further optimize metallic soft tissue foreign body extraction in children in a minimally invasive manner.

"Skin Popping" and "Shooter's Patch" As Manifestations of Intradermal Drug Abuse

Talc, a common adulterant in injectable opioids and filler in oral tablets, is frequently abused as crushed suspensions in injections. This review aims to recognize intradermal drug injection referred to colloquially as "skin popping" or "shooter's patch" as a cause of granulomatous disease and prevention of systemic complications from cutaneous cues.

Characteristics of Breast Charcoal Granuloma: A Delayed Complication Following Tattoo Localization

Rationale and Objective: To evaluate the characteristic clinical and imaging findings of charcoal granuloma and suggest features that may differentiate charcoal granuloma from breast cancer. Materials and Methods: This retrospective study included 18 patients with a histologically confirmed breast charcoal granuloma between 2005 and 2021 at a single institution. All patients had a history of breast surgery after ultrasound (US)-guided charcoal marking. Two radiologists analyzed the radiologic findings of charcoal granulomas, including the presence of a mass or calcification; the shape, margin and density of the masses on mammography; and the location, size, shape, margin, orientation, echogenicity, vascularity, presence of an echogenic halo, and posterior acoustic shadowing on US. In cases with available follow-up images, we also investigated whether the size and shape had changed. Results: The median interval between breast surgery and the diagnosis of charcoal granuloma was 2.3 years (range, 0.7-18.3 years). Thirteen lesions (72.2%) were detected on screening images. In 11 (61.1%) cases, the surgical incision was not made in the tattooed skin area. Mammography showed positive findings in 10/15 patients, and most lesions were isodense masses (70%). There were no cases with calcification. On US, all lesions were masses and showed a taller-than-wide orientation (61.1%), round or oval shape (55.6%), and iso- or hyperechogenicity (83.3%). Echogenic halo (27.8%) and posterior acoustic shadowing (16.7%) were uncommon. On Doppler US, only four cases (22.2%) showed increased vascularity. Most were classified as BI-RADS 3 (38.9%) or 4A (50.0%). After biopsy, 12 patients had follow-up mammography and US. The size of the lesion decreased in nine cases and remained unchanged in three cases. A decrease in the lesion size after biopsy showed a negative correlation with the interval between detection on imaging and biopsy (p = 0.04). Conclusion: Charcoal granuloma is most commonly found 2-3 years after surgery and occurs more frequently when the incision site is different from the tattooed skin area. US findings of tall and round or oval masses with iso- or hyperechogenicity without increased vascularity could help to differentiate them from malignancies.

Microblading-Induced Granulomatous Reaction: Case Report and Review of the Literature

ABSTRACT

Microblading is a common cosmetic procedure that can modify the appearance of one's eyebrows. Although generally well-tolerated, the procedure can cause a number of dermatologic issues; on rare occasions, granulomatous reactions can manifest. We use this case to highlight a presentation of a nonsarcoidal granulomatous dermatitis and review the literature on granulomatous reactions secondary to microblading. Of the 21 cases included in our review, approximately half (10/21) were diagnosed with foreign-body granulomas and the other half with sarcoidosis (7 of 21 with systemic sarcoidosis and 4 of 21 with cutaneous sarcoidosis). Although microblading remains a commonplace cosmetic technique, it is not without risk. Much like other types of tattoos, microblading can cause granulomatous reactions for which we must be vigilant, and further workup for sarcoidosis might be considered in select patients.

Don't Go Breaking My Heart: Not Your Ordinary Tattoo Reaction

ABSTRACT

Necrobiosis lipoidica (NL) is a rare, chronic idiopathic granulomatous dermatitis with a somewhat controversial association with diabetes and other systemic diseases. We report a case of NL developing within a polychromic tattoo on the lower leg of a 53-year-old woman. Characteristic histopathologic findings of both active and chronic "burnt-out" NL appeared to originate from the tattoo where red ink was used 13 years prior. To the best of our knowledge, only 3 other cases of tattoo-associated NL have been reported.

Foreign Body Granuloma Originating From the Lateral Process of Malleus: A Case Series of 19 Children

OBJECTIVE

A special presentation of foreign body granuloma originating from the lateral process of the malleus (FBGLP) was noted in the absence of a history of foreign body entry into the external auditory canal (EAC). This study reported the clinical features, pathology, and prognosis of patients with FBGLP.

DESIGN

Retrospective study.

SETTING

Shandong Provincial ENT Hospital.

PATIENTS

Nineteen pediatric patients (age, 1-10 yr) with FBGLP.

INTERVENTIONS

Clinical data were collected from January 2018 to January 2022.

MAIN OUTCOME MEASURES

Clinicopathologic characteristics of the patients were analyzed.

RESULTS

All patients had an acute course, and were within 3 months of ineffective medical treatment. The most common symptoms were suppurative (57.9%) and hemorrhagic (42.1%) otorrhea. FBGLP imaging examinations demonstrated a soft mass blocking the EAC without bone destruction and occasionally concomitant effusion in the middle ear. The most common pathologic findings were foreign body granuloma (94.7%,18/19), granulation tissue (73.7%, 14/19), keratotic precipitate (73.7%, 14/19), calcium deposition (63.2%, 12/19), hair shafts (47.4%, 9/19), cholesterol crystals (5, 26.3%), and hemosiderin (15.8%, 3/19). Foreign body granuloma and granulation tissue showed higher expression levels of CD68 and cleaved caspase-3 than did the normal tympanic mucosa, whereas Ki-67 levels were similarly low in all tissues. The patients were followed up for 3 months to 4 years without recurrence.

CONCLUSION

FBGLP is caused by endogenous foreign particles in the ear. We recommend the trans-external auditory meatus approach for FBGLP surgical excision, as this shows promising outcomes.

Comparative Immunohistochemical Analysis of Macrophage Phenotypes in Cutaneous Sarcoid Granuloma, Suture Granuloma, and Lipogranuloma

ABSTRACT

Granulomas are composed of a heterogeneous population of resident and recruited macrophages according to the type of lesion, extent of injury, and local tissue environment (eg, involved site and interaction with infiltrating lymphocytes). Although macrophage phenotypes in various types of granulomas have been previously described, the experimental conditions varied across studies, precluding a comparative and comprehensive understanding of granulomas. This study was conducted to comparatively analyze the expression of markers of the M1 and M2 phenotypes in macrophages that compose various types of granulomas, including epithelioid lesions, under strict conditions. Surgical specimens of cutaneous sarcoidosis (11 lesions), suture granuloma (10 lesions), and subcutaneous lipogranuloma (12 lesions) were immunohistochemically stained for CD11c, CD206, CD163, and CD10. The expression of these markers in macrophages composing each type of granuloma was scored and statistically analyzed. Granuloma macrophages were mostly immunoreactive for CD11c and CD206 in all the examined cases, although many intermingling CD206-negative cells were observed in 5 cases of lipogranuloma. CD163 and CD10 were diffusely expressed in macrophages composing suture granuloma and lipogranuloma, whereas they were not expressed in epithelioid cells in cutaneous sarcoidosis. Meanwhile, "interstitial" macrophages around epithelioid granulomas revealed moderate to marked CD163 expression in 7 lesions of cutaneous sarcoidosis. These results indicate significant differences of expression of CD163 and CD10 between cutaneous sarcoidosis and suture granuloma/lipogranuloma; CD163 and CD10 are downregulated after the epithelioid transformation of macrophages in cutaneous sarcoidosis.

Endogenous Interleukin-10 Contributes to Wound Healing and Regulates Tissue Repair

INTRODUCTION

Interleukin-10 (IL-10) is essential in fetal regenerative wound healing and likewise promotes a regenerative phenotype in adult dermal wounds. However, the role of endogenous IL-10 in postnatal dermal wound healing is not well-established. We sought to determine the function of endogenous IL-10 in murine full thickness excisional wounds that are splinted to prevent contracture and mimic human patterns of wound closure.

METHODS

Full-thickness excisional wounds were made in wildtype (WT) and IL-10-/- mice on a C57BL/6J background (F/M, 8 wk old). In a subset of wounds, contraction was prevented by splinting with silicone stents (stenting) and maintaining a moist wound microenvironment using a semiocclusive dressing. Wounds were examined for re-epithelialization, granulation tissue deposition, and inflammatory cell infiltrate at day 7 and fibrosis and scarring at day 30 postwounding.

RESULTS

We observed no difference in wound healing rate between WT and IL-10-/- mice in either the stented or unstented group. At day 7, unstented IL-10-/- wounds had a larger granulation tissue area and more inflammatory infiltrate than their WT counterparts. However, we did observe more F4/80+ cell infiltrate in stented IL-10-/- wounds at day 7. At day 30, stented wounds had increased scar area and epithelial thickness compared to unstented wounds.

CONCLUSIONS

These data suggest that endogenous IL-10 expression does not alter closure of full thickness excisional wounds when wound hydration and excessive contraction of murine skin are controlled. However, the loss of IL-10 leads to increased inflammatory cell infiltration and scarring. These new findings suggest that IL-10 contributes to the regulation of inflammation without compromising the healing response. These data combined with previous reports of increased rates of healing in IL-10-/- mice wounds not controlled for hydration and contraction suggest an important role for murine wound healing models used in research studies of molecular mechanisms that regulate healing.

Granulomatous annular diseases

Granulomatous skin disorders comprise a large group of diseases that are typically characterized by granuloma formation both in the skin and in many other tissues. Cutaneous lesions are usually seen as erythematous papules and plaques that may occasionally be arranged in an annular, ringlike configuration. The etiopathogenesis is unclear in most cases, and granuloma formation may be associated with various systemic, infectious, and metabolic disorders, foreign bodies, environmental antigens, or malignancies. Treatment options are dependent on the etiology, extent, and severity of the lesions. This review includes the clinical, histopathologic, and dermatoscopy findings, differentials, and treatment options for noninfectious granulomatous annular skin disorders.

A case report of a bullet in the breast of a woman for four years without any complications

INTRODUCTION AND IMPORTANCE

A bullet stabilized in a breast for more than 4 years without causing any complication due to its presence is not a common case. Sometimes breast isolated injury could be seen without symptoms like pain, or palpable mass, or it could present with abscess formation and fistula. In addition, the bullet - if it's small - could mimic calcifications seen in malignancy when performing mammography.

CASE PRESENTATION

We report a case of a 46-year-old well-being female who came to resect a superficial gunshot she got in her left breast in one of the armed conflict areas in Syria. The bullet has been settled there for more than 4 years without causing any inflammation-related signs at the wound's site and without causing any symptoms or complications.

CLINICAL DISCUSSION

The tissue damage caused by the gunshot is associated with several factors such as the bullet caliber, speed, range of shooting, and energy flux. Frequently, gunshot injuries are most serious in friable solid organs like the liver and brain, whereas dense tissues such as bones and loose tissues like subcutaneous fat are more tolerant and resistant to that kind of insult. When a foreign body (bullet) enters the body without causing tremendous tissue damage and settles there for enough period of time we expect seeing signs of inflammation (heat, swelling, pain, tenderness, and redness).

CONCLUSION

Such cases must be taken into consideration and not be neglected without intervention due to the increased risk of many fearful complications including Squamous Cell Carcinoma.

Synthesis, Characterization, and Optimization Studies of Polycaprolactone/Polylactic Acid/Titanium Dioxide Nanoparticle/Orange Essential Oil Membranes for Biomedical Applications

The development of scaffolds for cell regeneration has increased because they must have adequate biocompatibility and mechanical properties to be applied in tissue engineering. In this sense, incorporating nanofillers or essential oils has allowed new architectures to promote cell proliferation and regeneration of new tissue. With this goal, we prepared four membranes based on polylactic acid (PLA), polycaprolactone (PCL), titanium dioxide nanoparticles (TiO₂-NPs), and orange essential oil (OEO) by the drop-casting method. The preparation of TiO₂-NPs followed the sol-gel process with spherical morphology and an average size of 13.39 nm ± 2.28 nm. The results show how the TiO₂-NP properties predominate over the crystallization processes, reflected in the decreasing crystallinity percentage from 5.2% to 0.6% in the membranes. On the other hand, when OEO and TiO₂-NPs are introduced into a membrane, they act synergistically due to the inclusion of highly conjugated thermostable molecules and the thermal properties of TiO₂-NPs. Finally, incorporating OEO and TiO₂-NPs promotes tissue regeneration due to the decrease in inflammatory infiltrate and the appearance of connective tissue. These results demonstrate the great potential for biomedical applications of the membranes prepared.

Foreign body granuloma development after calcium hydroxylapatite injection for stress urinary incontinence: A literature review and case report

Objectives

To present a case of foreign body granuloma (FBG) development after injection of calcium hydroxylapatite as a urethral bulking agent and to review all documented cases of this phenomenon in the literature.

Methods

We analyzed a new case of calcium hydroxylapatite-induced FBG. We also conducted a literature review of the PubMed, Embase, CINAHL, and Web of Science databases through March 2022. Reports were included if they contained stress urinary incontinence patients that developed an FBG after calcium hydroxylapatite injection. The cases were reviewed for presenting symptoms, patient demographics, granuloma details, and surgical treatment.

Results

We screened 250 articles and included six articles between 2006 and 2015 in addition to the present case. The median age of the patients was 65.5 years (range 45-93), and all patients were female. The most common presenting symptoms and the proportion of patients affected were difficulty voiding (4/8), recurrent urinary incontinence (3/8), and dyspareunia (2/8). The median time between the first CaHA injection and discovery of the FBG was 5 months (range 1-50). The median longest dimension of the FBGs was 1.85 cm (range 1.0-3.0). The 8 masses observed were evenly distributed throughout the urethra, with 3 in the bladder neck, 2 in the midurethra, and 3 in the distal urethra. Surgical excision was the predominant management choice, with some variation in technique.

Conclusions

Severe, persistent lower urinary tract symptoms after calcium hydroxylapatite injection may indicate an FBG, which has been successfully managed with surgical excision.

Imaging Features of Soft Tissue Tumor Mimickers: A Pictorial Essay

Soft tissue lesions are commonly encountered and imaging is an important diagnostic step in the diagnosis and management of these lesions. While some of these lesions are true neoplasms, others are not. These soft tissue tumor mimickers can be due to a variety of conditions including traumatic, iatrogenic, inflammatory/reactive, infection, vascular, and variant anatomy. It is important for the radiologist and clinician to be aware of these common soft tissue tumor mimickers and their characteristic imaging features to avoid unnecessary workup and provide the best treatment outcome.

The dense-core plaques of Alzheimer's disease are granulomas

Dense-core plaques, whose centers contain highly polymerized and compacted aggregates of amyloid β peptides, are one of the two defining histopathological features of Alzheimer's disease. Recent findings indicate that these plaques do not form spontaneously but are instead constructed by microglia, the tissue macrophages of the central nervous system. We discuss cellular, structural, functional, and gene expression criteria by which the microglial assembly of dense-core plaques in the Alzheimer's brain parallels the construction of granulomas by macrophages in other settings. We compare the genesis of these plaques to the macrophage assembly of mycobacterial granulomas, the defining histopathological features of tuberculosis. We suggest that if dense-core plaques are indeed granulomas, their simple disassembly may be contraindicated as an Alzheimer's therapy.

[Granulomatous dermatoses]

The group of granulomatous dermatoses refers to a multitude of clinically different diseases, which are characterized by a histopathologically similar pattern of inflammation. The cause of granulomatous inflammatory reactions can be infections and also noninfectious stimuli, such as cell disintegration or foreign bodies. The aim of this immunological defence reaction is encapsulation in order to prevent further spread and delimitation from healthy tissue. This is histologically expressed as a granuloma in the sense of a circumscribed aggregation of histiocytes and multinucleated giant cells mostly in dermal connective tissue. The following can be histologically differentiated: sarcoid granuloma characterized by a sparse lymphocytic inflammatory infiltrate and tuberculous granuloma with central necrosis and denser lymphocytic inflammatory infiltrate. Neutrophilic granulocytes together with macrophages occur in suppurative granulomas and palisaded granulomas are characterized by peripherally arrayed macrophages.

Histopathology of Dermatologic Complications of Tattoos

ABSTRACT

Tattoos are characterized by the introduction of exogenous pigments into the dermis. Tattoos usually serve cosmetic purposes, although they may have other causes, such as traumatic pigment implants in accidents or medical-related tattoos in the context of radiotherapy. Dermatologic adverse reactions are relatively uncommon, and they include infections, immune-mediated reactions, cutaneous lesions secondary to the Koebner phenomenon, exacerbation of preexisting dermatosis, benign and malignant neoplasms, and a miscellaneous group of dermatologic conditions that may appear in a preexisting tattoo. The aim of this study is to review the types of histopathologic reactions that may appear in a preexisting permanent tattoo.

Prevention of peritendinous adhesions with electrospun poly (lactic acid-co-glycolic acid) (PLGA) bioabsorbable nanofiber: An experimental study

In this study, we investigated the application of poly (lactic acid-co-glycolic acid) in the rat Achilles tendon injury model for the prevention or alleviation of peritendinous adhesion and guidance of Achilles tendon regeneration. In the study, 48 rats were used and the rats were randomized by closed envelope method and divided into 4 mating groups in groups of 12. Left Achilles tendons of the non-PLGA-treated control group (groups 1 and 2) were cut and repaired. In the PLGA-treated groups (groups 3 and 4) the left Achilles tendons were cut and repaired, then PLGA bioabsorbable material was wrapped around the repair line. The rats in the 1st and 3rd groups were sacrificed at the end of the 1st month, and the rats in the 2nd and 4th groups at the end of the 2nd month. The degree of tendon adhesion in the Group 3 was lower in comparison with Group 1. Similarly, compared with Group 2, the degree of tendon adhesion in the Group 4 was lower. Inflammatory density, vascularization and fibrosis were higher in the experimental group. When the Group 3 and Group 1, and Group 2 and Group 4 were compared, adhesion length (p = 0.004, p = 0.041), adhesion characteristics (p = 0.049, p = 0.039) and adhesion severity (p = 0.007, p = 0.025) were found have statistically significant tendon healing in the PLGA-treated group, respectively. Significant difference was observed in inflammatory cell density, vascular density and fibrosis for Group 1 and Group 3, (p = 0.027, p = 0.041, p = 0.002), respectively. Similarly, significant difference was observed in inflammatory cell density, vascular density and fibrosis for Group 2 and Group 4, (p = 0.002, p = 0.027, p = 0.011), respectively. As a result, it was considered that poly (lactic acid-co-glycolic acid) material significantly reduces peritendinous adhesions, and this effect could occur with the vascular density, inflammatory density and fibrosis as indicated in histopathological examination. These data suggest that PLGA membrane has good biocompatibility and alleviates tendon adhesion after injury.

Suture granuloma with hydronephrosis caused by ileostomy closure after rectal cancer surgery: a case report

Background

Suture granuloma with hydronephrosis after abdominal surgery is extremely rare. We herein report a successfully treated case of suture granuloma with hydronephrosis caused by ileostomy closure after rectal cancer surgery.

Case presentation

A 63-year-old male underwent laparoscopic low anterior resection with covering ileostomy. Two months after primary operation, ileostomy closure was performed with two layered hand-sewn suture (Albert–Lembert method) using absorbable suture. In that operation, marginal blood vessels in the mesentery were ligated with silk suture. The patient had remained in remission with no evidence of tumor recurrence, however, 2 years and 5 months after primary surgery, a contrast-enhanced computed tomography (CT) scan showed a mass-forming lesion on the right external iliac artery (43 × 26 mm) and hydronephrosis. Positron emission tomography/computed tomography (PET/CT) showed a mass-forming lesion without high accumulation, which obstructed the right ureter. Recurrence could not be ruled out due to the rapid appearance of tumor and hydronephrosis in the short-term period. Thus, the patient underwent laparotomy. The tumor located in the mesentery near the anastomosis of ileostomy closure and it was strongly adherent to the retroperitoneum, which obstructed the right ureter. The adhesion between the tumor and ureter was carefully dissected and tumor resection with partial small bowel resection was then performed with preservation of the ureter using ureteral stents. Pathological examination of the tumor revealed fibrous proliferation of foreign body granuloma. In the resected tumor, sutures with foreign giant cells were found. Therefore, we diagnosed the tumor as silk suture granuloma, which was caused by the silk suture used to ligate blood vessels of the mesentery at the ileostomy closure. The patient remained well with no evidence of tumor recurrence as 5 years after the primary operation of rectal cancer.

Conclusions

Suture granuloma is a rare surgery-related complication in the postoperative surveillance of patients with colorectal cancer. If suture granuloma mimicking local recurrence is a differential diagnosis, it would be important to consider to avoid unnecessary extended resection.

Foreign Body Reaction Due to a Forgotten Rubber Band on the Neck of a Toddler Girl

ABSTRACT

In the presence of an unhealed granulation tissue-like wound, a possibility of abuse and neglect along with a foreign body should come to mind. However, it may be difficult to recognize a foreign body in patients with atypical clinical presentations. We demonstrated delayed diagnosis of a rubber band embedded into subcutaneous tissue in a 2½-year-old girl who presented with a circumferential scar with 2 granulation tissue-like wounds on her neck due to a foreign body reaction developed over years. With this rare case presentation, we remind the possibility of abuse/neglect along with foreign bodies in neck lesions of children.

Granulomatous Sarcoidosis Mimics

Many granulomatous diseases can mimic sarcoidosis histologically and in terms of their clinical features. These mimics include infectious granulomatous diseases, granulomatous reactions to occupational and environmental exposures, granulomatous drug reactions, vasculitides and idiopathic granulomatous conditions. It is important to distinguish sarcoidosis from these mimics, as a misdiagnosis of these diseases may have serious consequences. This manuscript reviews numerous sarcoidosis mimics and describes features of these diseases that may allow them to be differentiated from sarcoidosis. Distinguishing features between sarcoidosis and its mimics requires a careful review of the medical history, symptoms, demographics, radiographic findings, histologic features, and additional laboratory data. Understanding the clinical characteristics of sarcoidosis and its mimics should lead to more accurate diagnoses and treatment of granulomatous disorders that should improve the care of these patients. As the diagnostic criteria of sarcoidosis are not standardized, it is possible that some of these sarcoidosis mimics may represent varied clinical presentations of sarcoidosis itself.

Granulomas in Dermatopathology: Principal Diagnoses - Part 1

This series of 2 articles on dermatopathologic diagnoses reviews conditions in which granulomas form. Part 1 clarifies concepts, discusses the presentation of different types of granulomas and giant cells, and considers a large variety of noninfectious diseases. Some granulomatous diseases have a metabolic origin, as in necrobiosis lipoidica. Others, such as granulomatous mycosis fungoides, are related to lymphomas. Still others, such as rosacea, are so common that dermatologists see them nearly daily in clinical practice.

Hyperbaric oxygen therapy acts as an alternative method in treating injection-induced nodules

BACKGROUND

Cosmetic injection-induced nodules are tricky to handle in the clinic.

AIMS

We reported a case of injection-induced nodule receiving the experimental treatment of hyperbaric oxygen therapy (HOT).

PATIENT

A woman presented with multiple red solid nodules on the neck after receiving mesotherapy conducted by syringe. Ultrasound examination showed multiple thickened inflammatory skin tissues on the neck. Pathological biopsy results showed epithelioid granulomas in the dermis, within which there were degenerative necrosis and foreign bodies in the center and multinucleated giant cells around. The bacteria tests remained negative. Diagnosed with foreign body granuloma, the patient rejected the resection or steroids, but willingly took the experimental treatment of HOT instead. After one month, the patient's ultrasound examination showed that the lesion's local hardness got significantly reduced, and the local blood flow increased, indicating the condition improved.

RESULTS

Although the patient's nodule has not been eliminated, some improvements have been achieved. So far there has no case report on HOT treating injection-induced nodules in the literature.

CONCLUSION

HOT may be considered as a potential alternative when other treatment options cannot be implemented. More research is needed in this field.

Foreign body reaction toward hydrophilic polymer at the site of endovascular procedure: A report of two cases

Hydrophilic polymer-coated devices have been increasingly utilized for various endovascular procedures, however not been without adverse effects. We report two cases of subacute cutaneous lesions on the neck encountered in our dermatology clinic. Histopathologic findings were significant for a nodular aggregate of epithelioid histiocytes and lymphocytes with numerous foreign body giant cells in the dermis. The granulomatous infiltrate was associated with an amorphous basophilic non-polarizable material. Further chart review reveals both patients receiving a central venous procedure in the past, thus attributing the hydrophilic polymers as the likely source of the foreign material found at the insertion site. Our cases contrast to the more commonly reported distal embolization by these hydrophilic polymer layers. We suspect the incidence of retained hydrophilic polymer at the site of prior endovascular procedures may be underreported in the literature with the more inconspicuous presentations. Therefore, retained foreign material should be considered by both treating physicians and dermatopathologists in presenting cases of lesions that occur at common sites of endovascular procedures.

Histopathologic features of noninfectious granulomatous disorders involving the skin

Granulomatous dermatoses may represent primary skin inflammation or can serve as the harbinger of a multitude of underlying systemic disorders or drug reactions. Taken together with clinical findings, the microscopic features from skin biopsy can allow recognition of various patterns and facilitate a precise diagnosis. Accurate classification of entities in this category of inflammatory dermatoses may prompt clinicians to investigate for underlying systemic problems, thereby allowing the pathologist to add considerable value in the care of affected patients. This review article categorizes clinical and microscopic features of common and uncommon causes of noninfectious dermal and subcutaneous granulomatous inflammation.

Non-infectious granulomatous dermatoses

Granulomatous dermatoses comprise a wide range of etiologically and clinically distinct skin diseases that share a common histology characterized by the accumulation of histiocytes include macrophages. While the pathogenesis of these disorders is not fully understood, the underlying mechanism is thought to involve a reaction pattern caused by an immunogenic stimulus. Antigen-presenting cells and the effect of various cytokines play a key role. Our understanding of granulomatous reaction patterns has been advanced by insights drawn from observations of such reactions in patients on immunomodulatory therapy and in individuals with genetic immunodeficiency. Traditionally, a distinction is made between infectious and non-infectious granulomatous dermatoses. The present CME article addresses granulomatous skin diseases for which there is no evidence of a causative infectious agent. Common representatives include granuloma annulare, necrobiosis lipoidica and cutaneous sarcoidosis. Granulomatous dermatoses may be part of the clinical spectrum of various systemic disorders or may be associated therewith. Some neoplastic disorders may mimic granulomatous dermatoses histologically. Given the pathogenetic diversity involved, the clinical presentation, too, is quite varied. Overall, however, each disorder is characterized by typical clinical features. The diagnosis always requires thorough clinicopathologic correlation. Treatment is preferably based on the underlying pathogenesis and frequently involves anti-inflammatory agents. In most cases, however, there is insufficient study data. The dermal nature of these disorders frequently poses a therapeutic challenge, especially with respect to topical treatment.

Non-healing wounds: Can it take different diagnosis?

Wound healing is a complex cellular and biochemical process and can be affected by several systemic and local factors. In this study, we aimed to discuss the aetiologic factors of non-healing wounds and the management of this complicated process with current information. The medical data of the patients who were admitted to our clinic due to non-healing or chronic wounds were analysed retrospectively. A total of 27 patients were evaluated retrospectively during the 14 months of the study. The data of 6 patients who were followed up for chronic wound that developed after abdominal incisional hernia repair and pilonidal sinus surgery were not included in the study as their data could not be reached. A total of 21 patients were included in the study. Malignancy was diagnosed in two patients and granulomatous disease was found in four patients. The aetiology of the other cases included foreign body reaction, infection, and mechanical causes. Non-healing wounds are a serious social and economic problem for patients. Further studies on the pathophysiology of various aetiologies in non-healing wounds in both clinical settings and experimental animal models would be a useful step in treatment.

Cutaneous Crospovidone: A Newly Described Foreign Body Due to Illicit Drug Abuse

Crospovidone, a polymer of poly N-vinyl-2-pyrrolidone, is an inert insoluble disintegrant found in pharmaceutical tablets. This material has been encountered in the lungs of intravenous drug users and embolized with other components such as talc and microcrystalline cellulose. More recently, crospovidone has also been described in the gastrointestinal tract. We present 2 cases of cutaneous crospovidone deposition resulting from subcutaneous injection of crushed tablets, commonly known as "skin popping." Clinical presentation includes painful, inflamed papules, nodules, or ulcers with overlying eschar. Crospovidone has a distinct and reproducible histochemical staining profile. Histologic recognition of this material is important because it can guide clinicians in their diagnosis and management decisions.

Sea Urchin Granuloma of the Hands: A Case Report

Penetrating wounds from sea urchin spines are marine injuries that may cause morbidity in humans. Seasonal fishing for abalone in Dhofar is associated with an increase in the number of these injuries, as divers may strike their extremities, especially the dorsum of hands and fingers, on the rocks where Echinoderms and juvenile abalone (Haliotis mariae) are anchored. The immediate effect of injuries includes pain, edema, bleeding, erythema, and rarely systemic complications. There can be a delayed effect in the form of chronic granulomatous skin disease, which is a slow developing reaction to retained spine fragments in the wound that may take several months to develop. We report a case of sea urchin granulomas in a 45-year-old male who injured his hands by the spines of sea urchin while harvesting Haliotis mariae. Clinical manifestations, histological patterns, and treatment modalities are discussed here, to enhance the knowledge about these injuries and the available therapies.

Hydrolytic degradation and in vivo resorption of poly-l-lactic acid-chitosan biomedical devices in the parietal bones of Wistar rats

OBJECTIVES

This study sought to describe events related to the degradation/resorption of a device composed of polylactic acid (PLA) after implantation into Wistar rats.

METHODS

Five-millimeter-diameter PLA rigid scaffolds and flexible analogs were elaborated, bioactivated through culture with osteoblasts, and implanted into the parietal bones of adult Wistar rats after 15 days. After 3 months, the samples were recovered and analyzed via optical microscopy (histochemical techniques) and scanning electron microscopy. This research was approved by the animal ethics review committee of Universidad of Valle in Cali, Colombia, according to the endorsement of the ethics committee CEAS 001-016.

RESULTS

Initially, there was surface erosion and fragmentation of the device, inducing an inflammatory response compatible with the foreign body reaction, in addition to the presence of a pseudocapsule and a mixed inflammatory infiltrate that was responsible for phagocytosis of the material. Regeneration of the defect via the apposition of new bone occurred simultaneously with resorption of the material.

CONCLUSIONS

The results illustrated that the degradation/resorption of PLA occurs in a centripetal pattern.

Treatment of Granulomas in Patients With Ataxia Telangiectasia

Background: Ataxia telangiectasia (A-T) is a devastating multi-system disorder characterized by progressive cerebellar ataxia, growth retardation, immunodeficiency, chronic pulmonary disease and chromosomal instability. Cutaneous granulomas are a known phenomenon in A-T but extra-dermal manifestation of granulomas at bone and synovia has not been reported so far. The clinical presentation, immunological findings, the long-term course and treatment options of eight patients with severe granulomas will be reported.

Methods: From our cohort of 44 classical A-T patients, eight patients aged 2–11 years (18.2%) presented with granulomas. Immunological features of patients with and without granulomas were compared. Five patients suffered from cutaneous manifestation, in two patients we detected a bone and in one a joint involvement. Patients with significant extra-dermal involvement as well as one patient with massive skin manifestation were treated with TNF inhibitors. The patient with granulomas at his finger joint and elbow was treated with hematopoietic stem cell transplantation (HSCT).

Results: Interestingly, seven of eight patients with granulomas were total IgA deficient, but there were no differences in IgG and IgM levels. All lymphocytes subsets were equally distributed except patients with granuloma had significantly lower naïve CD8 cells. In patients without treatment, four of eight showed a slow but significant enlargement of the granuloma. Treatment success with TNF inhibitors was variable. In one patient, treatment with TNF inhibitors led to a total remission for 3 years up to now. In two patients, treatment with TNF inhibitors led to a partial regression of granulomas. Treatment interruptions caused deterioration again.

Conclusions: Granulomas in A-T progress slowly over years and can lead to significant morbidity.Treatment with TNF inhibitors was safe and in part successful in our patients. Interestingly HSCT leads to complete remission, and indicates that aberrant immune function is responsible for granulomas in A-T patients. What This Study Adds to the Field: Granulomas in A-T progress slowly over years and can lead to significant morbidity. Treatment with TNF inhibitors was safe and in part successful in our patients.

AT A GLANCE COMMENTARY:

Scientific knowledge on the subject: Little is known about the clinical presentation, course and treatment of granulomas in ataxia telangiectasia (A-T). In addition, this is the first report of extra-dermal manifestation of granulomas at bone and synovia in patients with A-T.

What This Study Adds to the Field: Granulomas in A-T progress slowly over years and can lead to significant morbidity. Treatment with TNF inhibitors was safe and in part successful in our patients.

Cutaneous Granulomatosis: a Comprehensive Review

Cutaneous granulomatosis is a heterogeneous group of diseases, characterized by a skin inflammatory reaction triggered by a wide variety of stimuli, including infections, foreign bodies, malignancy, metabolites, and chemicals. From a pathogenic point of view, they are divided into non-infectious and infectious granulomas. Pathophysiological mechanisms are still poorly understood. Non-infectious granulomatous skin diseases include granuloma annulare, necrobiosis lipoidica, rheumatic nodules, foreign body granulomas, cutaneous sarcoidosis, and interstitial granulomatous dermatitis. Necrobiosis lipoidica is more frequent in diabetic patients. Infectious granulomas of the skin are caused by mycobacteria, in particular Mycobacterium tuberculosis or atypical mycobacteria; parasites, such as Leishmania; or fungi. Pathogenic mechanisms of M. tuberculosis-related granuloma are discussed. From a clinical point of view, it is useful to divide cutaneous granulomatosis into localized and more disseminated forms, although this distinction can be sometimes artificial. Three types of localized granulomatous lesions can be distinguished: palisaded granulomas (granuloma annulare, necrobiosis lipoidica, and rheumatoid nodules), foreign body granulomas, and infectious granulomas, which are generally associated with localized infections. Disseminated cutaneous granulomas can be divided into infectious, in particular tuberculosis, and non-infectious forms, among which sarcoidosis and interstitial granulomatous dermatitis. From a histological point of view, the common denominator is the presence of a granulomatous inflammatory infiltrate in the dermis and/or hypodermis; this infiltrate is mainly composed of macrophages grouped into nodules having a nodular, palisaded or interstitial architecture. Finally, we propose which diagnostic procedure should be performed when facing a patient with a suspected cutaneous granulomatosis.

Pigmented Deposits in the Skin

Pigmented deposits can occur in the skin due to many and varied causes. Some of them are systemic conditions accompanied by involvement of internal organs. Others have serious prognostic implications, and early diagnosis can help in the correct and adequate management of the diseases. In addition, some of them are quite innocuous and the correct diagnosis avoids unnecessary treatments. In this article, we review the morphologic features of some of the most common and some of the less usual pigmented deposits in skin other than tattoos.