The spectrum of cutaneous granulomatous vasculitis: histopathologic report of eight cases with clinical correlation

Musculoskeletal Manifestations of Sarcoidosis

Since its initial description in the late 19th century, sarcoidosis has been extensively studied. Although the general mechanism of immune activation is known, many details especially in the context of disease associations are still missing. One of such associations is the musculoskeletal complications that are widely variable in terms of presentation and response to treatment. Sarcoidosis can involve the joints leading to acute and, less commonly chronic, arthritis. While acute arthritis is mostly self-resolving in nature, chronic arthritis may lead to deformity and destruction of the joint. Sarcoidosis can also involve the muscles, leading to different pathologies primarily categorized according to the clinical presentation, despite the efforts to find a new classification based on imaging, histological, and clinical findings. The bones can be directly and indirectly affected. Different types of bone lesions have been described, although around half of these patients remain asymptomatic. Osteoporosis, increased risk of fractures, hypercalcemia, and hypercalciuria are examples of the indirect effect of sarcoidosis on the bones, possibly contributed to elevated levels of calcitriol. Nevertheless, sarcoidosis can be associated with small-vessel, medium-vessel, and large vessel vasculitis, although it is frequently difficult to differentiate between the co-existence of a pure vasculitis and sarcoidosis and sarcoid vasculitis.

Eosinophilic granulomatosis with polyangiitis: Cutaneous clinical and histopathologic differential diagnosis

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare, but severe systemic vasculitis that can affect skin and other organ systems. Diagnostic criteria have evolved, and many attempts have been made to classify the vasculitides based on clinical and/or histopathologic features, with an aim to develop standardized criteria. According to the EGPA Consensus Task Force recommendations, EGPA is a syndrome of asthma, eosinophilia, pulmonary infiltrates, and extrapulmonary vasculitis (such as cutaneous involvement with purpura). Histopathologic evidence of vasculitis in EGPA may be associated with eosinophilic infiltration and/or perivascular granulomatous inflammation. We review clinicopathologic criteria of this enigmatic vasculopathy.

Interstitial granulomatous dermatitis and granulomatous arteritis in the setting of PD-1 inhibitor therapy for metastatic melanoma

Checkpoint inhibition has become an important target in the management of malignant melanoma. As anti-CTLA4 inhibitors and anti-PD1 antibodies are increasingly utilized, reports of immune-related adverse events (IRAEs) are becoming more frequent. Common noted cutaneous IRAEs are morbilliform, lichenoid, bullous, granulomatous, psoriasiform, and eczematous eruptions. We report a case of interstitial granulomatous dermatitis and granulomatous arteritis in the setting of nivolumab (anti-PD1) monotherapy for metastatic melanoma. There are many different causes for granulomatous vasculitis, such as herpes virus infection, lymphoproliferative disorders, systemic vasculitis, and inflammatory bowel disease. This report adds to the growing literature on granulomatous IRAEs due to checkpoint inhibition.

Facial purpura

OBJECTIVES

Patients with facial purpura can have acute and dramatic illnesses. For this reason, the clinician must be aware of certain diagnoses that can present as facial purpura and know how to initiate treatment efficiently. According to our review of the literature, no paradigm currently exists for the diagnosis and management of facial purpura Our goal is to develop a schema for the identification and management of facial purpura.

STUDY DESIGN

Case series.

METHODS

A case series of five cases is presented followed by a systematic development of a differential diagnosis based on etiology of the lesion.

RESULTS

Facial purpura can be classified into conditions that are primarily or secondarily vasculitic, thrombocytopenic, neoplastic, infectious, toxic, and miscellaneous, which encompasses episodic reports that do not fit into the other categories. A paradigm to diagnose patients with facial purpura is developed based on clinical presentation and etiology. To demonstrate the utility of our algorithm, the five cases presented are re-examined using the algorithm. To our knowledge, this represents the first reported series of facial purpura in the modern English literature. A flow chart based on our diagnostic paradigm is presented.

CONCLUSION

Clinicians caring for patients with facial purpura must recognize the acute conditions that require emergent medical intervention. Once these diagnoses have been considered, the clinician can employ a systematic approach to the diagnosis based on etiology. This study provides a useful reference for the otolaryngologist when encountering a patient with facial purpura.

Vasculitis-induced membranous fat necrosis

Membranous fat necrosis (MFN) a distinct degenerative process of adipose tissue, is characterised by the presence of membranocystic lesions (MCLs) superimposed on a background of typical traumatic-type fat necrosis. MCLs are cysts, of varying size and shape, that are lined by an eosinophilic, crenulated membrane, having the staining properties of ceroid. Although MFN has been documented in varying systemic adipose tissue sites and in tumours, the pathogenesis of this pathological curiosity is unknown. To date, an ischemic basis for MFN has been the most proximate, and atherosclerosis and venous insufficiency, due to large and medium vessel disease, have been the most popular underlying clinical disorders. Although systemic vasculitis has been quoted as the underlying ischemic disorder in some patients, vasculitis has not been commented on nor demonstrated in tissue sections in association with MFN. In,reporting vasculitis-induced MFN, we document the occurrence of MFN in association with uncommon causes of vasculitis, namely: 1) Granulomatous vasculitis in a post-herpetic zosteriform scar; 2) Cytomegalovirus-induced vasculitis in the clinical setting of systemic lupus erythematosus; and 3) Lymphocytic vasculitis in a tetanus toxoid immunization site reaction.

Granulomatous pigmented purpuric dermatosis

We report two cases of brown pigmentation accompanied by hemorrhagic papules. A 61-year-old woman and a 53-year-old woman presented with brown pigmentation accompanied with hemorrhagic papules occurring bilaterally from the dorsal aspect of the feet to the lower legs. The clinical picture was of pigmented purpuric dermatosis, but histopathologically, they were hemorrhagic granulomatous inflammation of the upper dermis. As no systemic granulomatous lesions were observed, these cases were considered to be granulomatous pigmented purpuric dermatosis.