Subcutaneous Vascular Malformations in Children: A Diagnostic Challenge

OBJECTIVES

There are various subcutaneous lesions in children and often there is difficulty in obtaining an accurate diagnosis by non-invasive diagnostic procedures. Subcutaneous granuloma annulare (SGA) is a rare granulomatous disease that, even after imaging, is often mistaken for a low-flow subcutaneous vascular malformation (SVM). This study aimed to accurately identify clinical and imaging clues to distinguish SGA from low-flow SVM.

METHODS

We retrospectively analyzed complete hospital records of all children with a confirmed diagnosis of SGA and low-flow SVM who underwent MR imaging at our institution from January 2001 to December 2020. Their disease history, clinical and imaging findings, management, and outcome were evaluated.

RESULTS

Among 57 patients with granuloma annulare, we identified 12 patients (nine girls) with a confirmed SGA diagnosis who underwent a preoperative MRI. Their median age was 3.25 years (range 2-5 years). Of 455 patients diagnosed with vascular malformations, 90 had malformations limited to the subcutaneous area. Among them only 47 patients with low-flow SVM were included in the study and further analyzed. Our SGA cohort had a female predilection (75%) and a short history of lump appearance of 1.5 months. SGA lesions were immobile and firm. Before MRI, patients underwent initial evaluation by ultrasound (100%) and X-ray (50%). Surgical tissue sampling was performed in all SGA patients to establish a diagnosis. All 47 patients with low-flow SVM were diagnosed correctly by MRI. A total of 45 patients (96%) underwent surgical resection of the SVM. A careful retrospective review of imaging findings of patients with SGA and SVM showed that SGA present as homogenous lesions in the shape of an epifascial cap with a typical broad fascial base extending towards the subdermal tissue in the middle of the lesion. In contrast, SVMs always present with variable-sized multicystic or tubular areas.

CONCLUSIONS

Our study shows clear clinical and imaging differences between low-flow SVMs and SGA. SGA presents characteristically in the shape of a homogenous "epifascial cap," which distinguishes these lesions from multicystic heterogenous SVMs.

Subcutaneous granuloma annulare mimicking dermatomyositis

We present three children who presented with papules and plaques over the knuckles, mimicking Gottron's papules of juvenile dermatomyositis, as well as subcutaneous nodules over the joints of the extremities that were initially thought to represent calcinosis cutis. However, thorough clinical and laboratory evaluation, as well as imaging, failed to support this diagnosis. Skin biopsies were consistent with a diagnosis of subcutaneous granuloma annulare. This unique phenotype of granuloma annulare should be recognized in order to prevent erroneous diagnosis and treatment.

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.

Usefulness of ultrasonography in the diagnosis of subcutaneous granuloma annulare

Subcutaneous granuloma annulare is a benign inflammatory disorder that primarily affects healthy children and manifests as a rapidly growing, painless, nonmobile mass, most commonly located in the leg. The current case highlights the sonographic appearance of subcutaneous granuloma annulare. Ultrasound color Doppler is a helpful noninvasive imaging test that may allow physicians to confirm the diagnosis of subcutaneous granuloma annulare and avoid unnecessary medical procedures.

Asymptomatic Papulo-nodules Localized to One Finger

Subcutaneous or deep granuloma annulare is a benign asymptomatic condition characterized by firm asymptomatic nodules in deep subcutaneous tissues that may be associated with intradermal lesions. A 53-year-old female presented with asymptomatic skin-colored, firm nodules over the right ring finger. Histopathology revealed a palisading granuloma with central degenerated collagen and mucin deposition in the dermis suggestive of granuloma annulare. Isolated and unilateral involvement of a single digit with clusters of nodules of subcutaneous granuloma annulare (GA) in an adult is rare and differentiation from its simulator rheumatoid nodule is essential.