Deep granuloma annulare (pseudorheumatoid nodule) in children: clinicopathologic study of 35 cases

Subcutaneous nodules in children: Don't forget deep granuloma annulare: A Case Report

Deep granuloma annulare is an uncommon benign granulomatous skin disorder that presents almost exclusively in the paediatric population. It presents as an asymptomatic subcutaneous nodule with normal overlying skin on distal extremities, the scalp, or the forehead. It shows a deep palisading granuloma with areas of central necrobiosis on histologic examination. Due to its self-limited nature, clinical follow-up is recommended over surgical interventions. We present a case of cephalic deep granuloma annulare in a healthy 5-year-old girl who remains free of recurrence after surgical excision at the 6-month follow-up. Our case emphasizes the importance of differentiating the lesion from its clinical and histopathological mimickers, such as the rheumatoid nodule. The awareness of this entity is important to avoid the overinvestigation and overtreatment of a benign and self-limited disease.

Subcutaneous granuloma annulare on the heel: A case report and review of the Japanese published work

Subcutaneous granuloma annulare is a rare variant of granuloma annulare. It mostly presents as painless subcutaneous nodule(s) with or without annular lesions on the lower legs and scalp of children. We herein report a case of a 5-year-old Japanese girl with subcutaneous granuloma annulare on the right heel. The lesions improved in 15 months without any therapy. We also review 85 reported cases of subcutaneous granuloma annulare between 1 and 85 years of age in the Japanese published work. The most susceptible age was 5 years and below; however, a small peak occurred from the 40s to 60s. Subcutaneous granuloma annulare was more frequent in females (male : female ratio, 6:11). Sixty-five cases (76.4%) had multiple lesions; the average number of lesions was 4.8 ± 5.8. The most affected site was the lower legs (28 cases), followed by the dorsum of the foot (21 cases) and scalp (17 cases). The heel was an unusual location; only two cases of sole subcutaneous granuloma annulare have been reported. Twenty-one cases revealed a classical dermal change along with a subcutaneous change. Patients with classical dermal lesions were younger (P < 0.0001) and had a smaller number of lesions (P < 0.05) than those without the lesions. The lesion(s) resolved in 24 of the 44 untreated cases within 1 week to 19 months. Refractory or recurrent lesion(s) were seen in four of 21 treated cases and in four of 44 untreated cases. Because subcutaneous granuloma annulare lesions often resolve spontaneously without treatment, invasive treatments should be avoided.

Common and critical inflammatory dermatoses every pathologist should know

Inflammatory dermatopathology remains a challenging area for surgical pathologists. Yet every surgical pathologist encounters inflammatory dermatoses as part of routine practice. This review will focus on selected diagnoses that are either commonly encountered in the routine practice of surgical pathology or are critically important. The following entities will be covered: spongiotic dermatoses, lichen simplex chronicus, and early lichen sclerosus in the setting of vulvar biopsies, as well as graft versus host disease, Stevens-Johnson syndrome/toxic epidermal necrolysis, granuloma anulare, pyoderma gangrenosum, and calciphylaxis. Practical points and key histologic features will be emphasized.

Contributions of Dr. Louis "Pepper" Dehner to the art of cutaneous pathology, the first pediatric dermatopathologist

Dr. Louis "Pepper" Dehner has been one of the most influential surgical pathologists of the last century. Authoring more than 450 publications, he is the premier modern pediatric pathologist. Perhaps, an area that he is less recognized and in which we would like to describe his contributions, is his role as a creator of the art of pediatric dermatopathology. Dr. Dehner has had at least 50 major publications describing, discovering, and orienting the discipline in the fields of fibrohistiocytic disorders of childhood, vascular tumors, and histiocytosis among many others. Dr. Dehner has clearly manifested that while many similarities between adult and pediatric surgical pathology exist, "children get different diseases." It is because of his mindful analysis and translation of the clinico-pathologic and biologic correlative between specific entities and advances in the field he has made that we are honored to describe some of his contributions to this particular area.

Mucin as a diagnostic clue in dermatopathology

Mucins are high-molecular weight glycoproteins typically found in normal skin in small amounts. There are several reports regarding different types of cutaneous mucinosis. In this report, we discuss mucins in dermatopathology as a diagnostic clue of some well-known entities and some less frequent cutaneous diseases. We also emphasize mucin as a sign in the differential diagnosis between conditions that show histopathological overlap. Lastly, we discuss the locations and circumstances in which mucin could be considered almost normal or physiological.

A Case of Subcutaneous Granuloma Annulare (SGA) in the Scalp of a Child: Histological Findings

Subcutaneous granuloma annulare is type of granuloma annulare which usually occurs in children. Scalp involvement is rare. The authors report a 3-year-old girl with subcutaneous granuloma annulare confirmed by imaging and histologic findings. No treatment was provided. The patient was followed for 6 months with no considerable complications.

Subcutaneous granuloma annulare of the penis associated with a urethral anomaly: case report and review of the literature

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

An unusual presentation of subcutaneous granuloma annulare in association with juvenile-onset diabetes: case report and literature review

Subcutaneous granuloma annulare (SGA) is a rarely reported subtype of granuloma annulare that occurs almost exclusively in children. The etiology of these lesions is unknown, although a possible relationship to insulin-dependent diabetes mellitus (IDDM) has been proposed in the literature. Here we present an unusual case of SGA on the right forearm in a 3-year-old girl. Unlike the typical lesions noted on the extremities, on magnetic resonance imaging her lesions involved the subcutaneous tissue and adjacent muscles in multiple locations. Histopathologically, the case was consistent with SGA but was unusual in its distribution involving multiple muscles, a finding that has not been previously reported. Weeks after incisional biopsy, she was readmitted with diabetic ketoacidosis (DKA) secondary to IDDM. After treatment of her DKA and control of her glycemia, the forearm SGA vanished, which supported the pathologic diagnosis and alleviated our concerns secondary to the unusual distribution.

Isolated intra-articular pseudorheumatoid nodule of the knee

The authors describe a case of an isolated intra-articular pseudorheumatoid nodule of the knee in an 18-year-old male patient without a diagnosis of rheumatoid arthritis. The patient initially presented with a 3 year history of anterior knee pain and was found to have a 2.8 × 2.1 cm lobulated soft-tissue mass. Histologic findings showed fibrinoid necrosis and chronic inflammatory changes that were consistent with those of a pseudorheumatoid or rheumatoid nodule, and surgical excision of the nodule was curative. A review of the literature revealed no prior cases of an intra-articular pseudorheumatoid nodule or rheumatoid nodule in a patient without clinical or serologic evidence of rheumatoid arthritis.

Granuloma annulare of the penis: a uncommon location for an usual disease

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

Periocular granuloma annulare in four children

Subcutaneous granuloma annulare is a skin condition that occurs on the lower extremities, hands, and scalp of healthy children. It rarely occurs in the periocular area, and when it does, the annular pattern is often absent. Histopathology is diagnostic and shows palisading histiocytes around areas of necrobiosis. Although benign in nature, the lesions tend to multiply, grow in size, and often recur. They usually resolve spontaneously and do not require treatment. Four cases of periocular subcutaneous granuloma annulare, from four different geographical areas, were identified through on-line postings on the worldwide mailing list of the Organization for Pediatric Ophthalmology and Strabismus (http://lists.ucsd.edu/mailman/listinfo/ped-ophth-1). These 4 patients are reported here, and a brief review of the literature is presented.

Surgical management and outcome of scalp subcutaneous granuloma annulare in children: case report

OBJECTIVE

Subcutaneous granuloma annulare (SGA) is a benign inflammatory disorder that rarely affects the scalp. We report 5 cases of children with SGA scalp lesions and discuss our clinical experience and the characteristic findings, diagnostic evaluation, method of treatment, and course of the disease.

CLINICAL PRESENTATION

Five patients presented with multiple subcutaneous nodules at single or multiple sites overlying the scalp. A retrospective review of the medical, surgical, and pathology records of the 5 patients was conducted.

INTERVENTION

All scalp lesions were excised and were confirmed histologically to be SGA nodules. In 4 of the 5 patients, the nodules were nontender and nonmobile. The mean number of lesions was 4.2. The mean age of patients at presentation was 3.8 years. Of the 5 patients, 4 experienced at least 1 recurrence of a solitary lesion at either the same site or a different site. In the 80% of patients who experienced a recurrence, all lesions recurred less than 1 year postoperatively, except in the case of 1 patient who continued to experience a disappearance and reappearance of lesions at 72 months. The ultimate diagnosis of all lesions was established through biopsy and subsequent microscopic evaluation. No postoperative complications were noted.

CONCLUSION

Granuloma annulare should be included in the differential diagnosis whenever a scalp subcutaneous superficial nodule is observed. Although many modalities of treatment for SGA nodules are used, recurrence is common, even with surgical excision.

Multiple deep granuloma annulare limited to the cephalic segment in childhood

Deep granuloma annulare is a rare variance of granuloma annulare. We present a 4-year-old boy with 30 lesions located only in the scalp with spontaneous regression of all lesions.

Subcutaneous (deep) granuloma annulare in children: a possible mimicker of epithelioid sarcoma

Subcutaneous granuloma annulare (SGA) is a self-limited inflammatory lesion consisting of dermal or subcutaneous nodules usually affecting children. Lower extremity involvement is the most common anatomic site. Because of the subcutaneous location, the morphological diagnosis of SGA can be challenging, and differential diagnoses are both benign and malignant processes including epithelioid sarcoma. Our article examines the clinical, histopathological, and immunohistochemical aspects of SGA in comparison to ES. We present 3 cases of SGA in children, who were initially diagnosed with ES and discuss the differential diagnoses features between SGA and ES. Because SGA can simulate ES, the awareness of this possibility is important to avoid overtreatment, like amputation, of the benign condition (SGA).

Large benign rheumatoid nodules of the trunk in an elderly patient: radiologic appearance mimicking a soft-tissue sarcoma

An 80-year-old woman without any evidence of rheumatoid arthritis presented with two large (maximum diameter: 6 cm and 7 cm), rapidly growing, rubbery nodules on the trunk. Although the clinical and radiological appearance suggested malignancy, the nodules were pathologically identical to rheumatoid nodules in rheumatoid arthritis, and the nodules regressed spontaneously. The final diagnosis was benign rheumatoid nodules. Recognition of this rare clinical entity is important to avoid unnecessary examination and treatment.

Pseudorheumatoid nodule in the liver of an adolescent male

Focal hepatic lesions in the pediatric population are rare and are usually found on incidental imaging of the abdomen. The most common lesions are focal nodular hyperplasia and hemangioma, but the differential diagnosis is quite broad. We present a case of an adolescent male who was found to have a large pseudorheumatoid nodule of the liver that was successfully resected. Only one previous case is reported in the literature and none in the pediatric age group.

Subcutaneous granuloma annulare in a child's palm: a case report

We present a rare case of subcutaneous lesions arising in the palm of a 4-year-old girl. Histologic examination of the biopsy specimens showed granulomatous inflammation with focal necrobiosis, which was consistent with subcutaneous granuloma annulare. Subcutaneous granuloma annulare is a self-limited disease and treatment is not required, although recurrence and/or multiple lesions are frequent.

Subcutaneous granuloma annulare of the penis in 2 adolescents

Granuloma annulare (GA) is a benign inflammatory disorder of unknown etiology characterized histologically by dermal palisading granulomas with central degeneration of collagen (necrobiosis). There is a rare subcutaneous clinical variant, this occurring more frequently in children than in adults and very rarely involves the penis. We describe 2 cases of penile subcutaneous GA developing in adolescent boys who to our knowledge has not previously been described in literature. Both were initially treated with surgical excision. Circumcision was performed on one of the boys, with subsequent improvement with the resolution of most of the nodules. Granuloma annulare of the penis is very rare, with only 7 cases reported to date [Narouz N, Allan PS, Wade AH. Penile granuloma annulare. Sex Transm Infect 1999;75(3):186-7; Trap R, Wiebe B. Granuloma annulare localised to the shaft of the penis. Scand J Urol Nephrol 1993;27(4):549-51; Laird SM. Granuloma annulare of the penis. Genitourin Med 1992;68(4):277; Hillman RJ, Waldron S, Walker MM, et al. Granuloma annulare of the penis. Genitourin Med 1992;68(1):47-9; Kossard S, Collins AG, Wegman A, et al. Necrobiotic granulomas localised to the penis: a possible variant of subcutaneous granuloma annulare. J Cutan Pathol 1990;17(2):101-4] and no previous reports in children or adolescents to our knowledge. All except one of the cases reported so far were of the subcutaneous (nodular) form of GA.

Congenital subcutaneous granuloma annulare

Granuloma annulare is a palisading granulomatous skin disease which may be generalized, localized, perforating, or subcutaneous. Subcutaneous granuloma annulare is self-limiting, affecting infants and children, with typical postnatal onset. Here we report a patient with congenital clinical manifestations.

Pseudorheumatoid Nodules in Adults

Pseudorheumatoid nodules are considered a deep form of granuloma annulare. Most cases are described in children, occur mainly on the lower legs and scalp, and have favorable prognosis. Their appearance in adults is rare. In this series, fourteen women with pseudorheumatoid nodules were studied. The average age of onset was 36 years old. Lesions consisted of erythematous, violaceous, or skin-colored nodules located mainly on the small joints of the hands. None of the patients developed collagen vascular disease. Persistence was common. Biopsy specimens showed deep dermal nodules composed of epithelioid granulomata separated by thickened collagen bundles. In some areas eosinophilic material was surrounded by histiocytes in a palisaded array. Granuloma annulare was present at the periphery of eight cases. Special stains revealed that most of the eosinophilic material was collagen and mucin was present in eleven cases. In sum these findings demonstrate that pseudorheumatoid nodules in adults are a distinct clinical and pathologic entity, which may be mistaken for rheumatoid nodules. They are probably a juxta-articular variant of granuloma annulare.

Expression of the histiocytic marker PG-M1 in granuloma annulare and rheumatoid nodules of the skin

BACKGROUND

The expression of PG-M1, the most specific histiocytic marker, has not yet been studied in granuloma annulare (GA) and other palisaded granulomas of the skin. We evaluated the reactivity of PG-M1 with a series of GA and rheumatoid nodules (RN) to establish the sensitivity and potential usefulness of this marker in the diagnosis and characterization of these entities.

METHODS

Histological sections from 30 GA and 15 RN were immunostained with PG-M1. For comparison, additional sections were stained with KP-1 and lysozyme. The stains were recorded as negative, weakly positive (1+) and strongly positive (2+).

RESULTS

PG-M1 stained all cases of GA (100%). KP-1 and lysozyme stained 26 (86%) and 18 (60%) GA cases, respectively. PG-M1 exhibited a significantly stronger staining intensity (1.8 +/- 0.07) when compared with KP-1 (1.4 +/- 0.13) (p = 0.018) and with lysozyme (0.9 +/- 0.15) (p < 0.0001). All RN were stained by PG-M1 (100%). KP-1 and lysozyme stained 14 (93%) and six (40%) RN cases, respectively. PG-M1 staining intensity (1.6 +/- 0.13) was slightly higher than that of KP-1 (1.4 +/- 0.18) (p = 0.27) and significantly higher than that of lysozyme (0.4 +/- 0.13) (p < 0.0001).

CONCLUSIONS

PG-M1 is consistently and strongly expressed by the histiocytic population of GA and RN, being more sensitive and reliable than other histiocytic markers. We recommend its use in difficult cases in which the histiocytic nature of the lesion needs to be confirmed.

Multiple palisading granulomas in the scalp of an infant: a case report

BACKGROUND

We describe an unusual lesion that represents an uncommon but important element in the differential diagnosis of subcutaneous scalp nodules in a child.

CASE DESCRIPTION

A 1-year-old boy presented with two clusters of subcutaneous scalp nodules. The lesions increased in size and number. Computed tomography showed no changes in underlying bone. Findings on magnetic resonance imaging were nonspecific. Serologic and clinical evaluation showed no evidence of rheumatic disease. Complete excision of the nodules, together with adjacent fascia and galea, was performed. Histopathologic examination showed the lesions to be palisading granulomas; given the absence of rheumatic disease, these represented deep granuloma annulare, a benign condition. No recurrence has been observed in our patient.

CONCLUSION

While we chose total excision because of preoperative concerns about a possible malignant tumor, some other authors have suggested that surgery be limited to confirmatory biopsy when a benign lesion such as palisading granuloma is strongly suspected.