Granuloma annulare as an isotopic response to herpes zoster

BACKGROUND

Wolf's isotopic response is the phenomenon of a new skin disease occurring at the site of another unrelated and already healed skin disorder. Most cases in the literature report herpes zoster (HZ) as the original disease; however, the isotopic responses vary greatly. Including this case, our literature search revealed 32 cases of isotopic granuloma annulare (GA) following HZ.

CASE REPORT

An 82-year-old male presented with GA localized to the right T9 dermatome that later appeared at other sites on the trunk and extremities. The patient had an episode of shingles involving the same dermatome 4 years earlier.

DISCUSSION

To our knowledge, this is the first case report of GA occurring initially as an isotopic response in an HZ scar and subsequently becoming generalized. Thirty-eight percent (12 of 32) of patients with isotopic GA following HZ were immunocompromised, which is similar to the published rate of immunodeficiency in patients with HZ.

Generalized granuloma annulare associated with chronic hepatitis B virus infection

We describe a 63-year-old Chinese woman with generalized granuloma annulare (GGA) associated with chronic hepatitis B virus (HBV) infection for 10 years. She developed non-annular papule lesions after a previous infection of hepatitis B virus. Since then, her clinical course was aggressive with involvement of the trunk, extremities and neck. Histologically, granulomatous inflammations were found in the upper to mid dermis. The HBV DNA in these lesions was demonstrated by polymerase chain reaction (PCR). GGA was totally regressed after treatment of interferon-alpha for 3 months. To the best of our knowledge, GGA associated with chronic HBV infection has never been reported in literature. The prognostic significance of the association of granulomatous inflammation and virus infection is reviewed.

Granuloma annulare and human immunodeficiency virus infection

OBJECTIVES

To characterize human immunodeficiency virus (HIV)-associated granuloma annulare (GA) by clinical, microscopic, and molecular methods and to investigate the role of Epstein-Barr virus infection in the pathogenesis of GA.

DESIGN

Patients were evaluated clinically, and biopsy specimens of lesional skin were examined by light microscopy. Polymerase chain reaction and in situ hybridization for Epstein-Barr virus were performed on 4 and 12 biopsy specimens, respectively.

SETTING

Academic referral center.

PATIENTS

Thirty-four consecutive HIV-positive patients who have a clinical and histological diagnosis of GA.

OUTCOME MEASURES

Clinical distribution of lesions, light-microscopic features, and the presence of Epstein-Barr virus DNA and RNA in biopsy specimens.

RESULTS

Granuloma annulare was generalized in 20 patients and localized in 14. Twenty patients (59%) presented with acquired immunodeficiency syndrome. Unusual features were the presence of oral lesions in 1 patient, perforating lesions in 2 patients, and the coexistence of GA and Kaposi sarcoma in 1 biopsy specimen. Microscopic examination of 34 biopsy specimens showed a granulomatous pattern that was interstitial in 8, palisaded in 18, perforating in 2, and mixed interstitial and palisaded in 6. Special staining of all specimens was negative for organisms. Epstein-Barr virus infection was not detected by either polymerase chain reaction or in situ hybridization.

CONCLUSIONS

Generalized GA is the most common clinical pattern in HIV infection. Granuloma annulare associated with HIV can present at all stages of HIV infection, but it is slightly more common in patients with acquired immunodeficiency syndrome. Epstein-Barr virus is an unlikely causative agent of HIV-associated GA. Granuloma annulare may be a manifestation of increasing immune dysregulation.

[Granuloma annulare after herpes zoster: isotopic response]

A 33 year-old woman was seen with a localized zosteriform papular eruption in a Th7 dermatomal distribution. The patient experienced neuralgic pain. A skin biopsy demonstrated palisading granulomatous dermatitis and a diagnosis of granuloma annulare after a subclinical herpes zoster infection was made. "Isotopic response" describes the occurrence of a new disorder at the site of another, unrelated, and already healed skin disease.

Viral glycoproteins in herpesviridae granulomas

Granulomatous reactions after varicella zoster virus (VZV) and herpes simplex virus (HSV) infections are rare, and their pathogenesis remains unclear. We studied by immunohistochemistry and in situ hybridization early granulomatous reactions after VZV and HSV infections. In the five cases studied, the VZV glycoproteins gp I and gp II were present in cells abutted to altered vessels, but the corresponding genome sequences were disclosed in similar locations in only one of these cases. In an immunocompromised patient with diffuse HSV eruption, HSV I antigens were present in cells of the reticular dermis, while viral nucleic acids were not evident. Immunophenotyping of the granulomas showed strong Mac 387 and CD68 positive labelings of macrophages/monocytes, without any involvement of Factor XIIIa-positive cells. These findings suggest that the major viral envelope glycoproteins, rather than complete viral particles could trigger granuloma formation following HSV and VZV skin infections.