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.

Pulse Granuloma-Like Reaction on the Forearm Following an Accidental Wound

ABSTRACT

Pulse granulomas are uncommon reactions to vegetable exogenous matter characterized by the presence of hyaline rings. Although they are usually found in the oral cavity or along the gastrointestinal or respiratory tracts, there are a few cases described outside those regions. We present the first case of a granulomatous reaction with hyaline rings in the skin reaction after an accidental wound and suggest the term pulse granuloma-like to describe lesions that resemble pulse granulomas but with no connection to the gastrointestinal or respiratory tracts. Moreover, we provide a graphic comparison of the hyaline rings observed in our case and the histologic sections of some plants that could have been involved.

Oral pulse granuloma and oral pulse granuloma associated with odontogenic keratocyst: Two clinical cases and a review of the literature

Two cases of oral pulse granuloma (OPG) or vegetable granuloma (VG) are presented, one of which was concomitant with an odontogenic keratocyst (OKC), which is an unusual finding. OKC is characterized by the presence of hyaline rings which include vessels, giant cells, other inflammatory cells and collagen fibres. There are two hypotheses as to its histogenesis: firstly, as a reaction to vegetable matter, such as legumes (thus the nomenclature "pulse" or edible seed) and secondly as a degenerative change in the vessel walls as a result of localized vasculitis. Due to the deceptive appearance of OPG, diagnosis can be challenging.

A Case of Hypercalcemia and Overexpression of CYP27B1 in Skeletal Muscle Lesions in a Patient with HIV Infection After Cosmetic Injections with Polymethylmethacrylate (PMMA) for Wasting

Foreign body-induced granuloma is an uncommon yet clinically significant cause of hypercalcemia. The molecular mechanisms are uncertain, although extrarenal calcitriol production has been proposed. We describe severe hypercalcemia associated with increased levels of plasma calcitriol in a patient with HIV and local granulomatous reaction 5 years after injection of polymethylmethacrylate (PMMA) as dermal filler for cosmetic body sculpting. Extensive evaluation revealed no identifiable cause of increased calcitriol levels. Nuclear imaging was remarkable for diffuse uptake in the subcutaneous tissues of the buttocks. Subsequent muscle biopsy and immunohistochemical staining showed strong local expression of CYP27B1 within histiocytes surrounding globules of PMMA. This case highlights an unfortunate complication of dermal fillers and shows that inflammatory cells can express high levels of CYP27B1 even without frank granulomas. The growing trend of body contour enhancement using injectable fillers should raise suspicion for this cause of hypercalcemia in clinical practice. Patients with HIV who receive this treatment for lipodystrophy or other cosmetic purposes may have increased susceptibility to hypercalcemia in the setting of underlying chronic inflammation. This may be a concern when changing anti-retroviral therapy, since alterations in levels of HIV viremia may initiate or contribute to worsening hypercalcemia.

ANTERIOR CHAMBER SYNCHYSIS SCINTILLANS: A CASE REPORT

Synchysis scintillans is a vitreous condition in which multiple golden brown opacities are formed as a result of chronic vitreous hemorrhage. Anterior chamber synchysis scintillans was described in patients with afakia or lens subluxation. We report a case of a 63-year-old man with a history of left eye trauma and complete loss of vision, who presented for left eye discomfort. The slit lamp examination revealed crystals of synchysis scintillans and rare inflammatory cells in the anterior chamber, stromal iris atrophy, circumferential posterior iris synechiae, and complete lens opacity. Total retinal detachment was observed on ocular ultrasonography. Intraocular pressure value was in normal range. The distinctiveness of this case is the mechanism of vitreous crystals mobilization into the anterior chamber through an atrophic iris while intraocular pressure remains normal.

Compressive Optic Neuropathy Caused by Cholesterol Gran- uloma in the Posterior Ethmoid Sinus

PURPOSE

Cholesterol granuloma is usually associated with chronic middle ear disease. Involvement of the ethmoid sinus by cholesterol granuloma is rare. We describe a case with cholesterol granuloma of the posterior ethmoid sinus causing optic nerve compression. No previous reports were found in our review of the literature.

CASE REPORT

A 48-year-old man had impaired visual acuity and a relative afferent pupillary defect in the right eye. Fundus fluorescein angiography showed a swollen optic nerve head and optic disc leakage. Automated perimetry revealed a severe peripheral visual field defect with tunnel vision. Computerized tomography demonstrated an expansile, isodense mass in the right posterior ethmoid sinus, remodeling of the bony walls of the right sphenoid sinus, and lateral displacement of the optic nerve in the right orbit. Compressive optic neuropathy caused by posterior ethmoid sinus lesion was diagnosed. A transnasal endoscopic exploration of the right ethmoid sinuses demonstrated a soft expansile cystic lesion with a thick yellow cap sule that filled the inside of the posterior ethmoid sinus. Brownish fluid with shiny crystals was drained by fine needle aspiration. The capsule was removed completely, and the mucociliary clearance of the sinus was reestablished. The pathologic pictures confirmed the diagnosis of cholesterol granuloma, which included typical cholesterol clefts surrounded by inflammatory cells with focal multi-nucleated giant cells. Visual function fully recovered without recurrent lesions after a three-year follow-up.

CONCLUSION

Compressive optic neuropathy can be rarely caused by cholesterol granuloma in the posterior ethmoid sinus. The visual prognosis may be good after transnasal endoscopic decompression in such patients.

Neck lymphadenitis due to silicone granuloma after mammary implants

INTRODUCTION

A foreign body reaction due to silicone where it is infiltrated or at the places to which it can migrate is known as siliconoma. The use of silicone in breast augmentation procedures can provoke this reaction at the neck level in cases of leakage from mammary implants.

METHODS

We reviewed the cases of patients with increased size neck lymph nodes who had previously undergone plastic surgery of the breast with highly cohesive silicone gel implants.

RESULTS

In a 10-year period, we identified 12 cases with silicone-infiltrated neck lymphadenopathies, histologically confirmed by fine needle aspiration. They represented 3.5% of patients attended for neck lymph node study. We removed those detected by physical examination and CT in 5 cases, due to pathological characteristics of the node or a previous malignant history. In 2 of these nodes recurred, and node size also increased in 2 of the other 7 non-operated cases. After implant removal, silicone leakage was observed in only 7 cases.

CONCLUSIONS

Cohesive gel silicone used for mammary implants can generate increased neck lymphadenopathies as a secondary effect due to systemic reactions against the silicone when it migrates in cases of implant failure. Surgical options for involved nodes usually do not offer good long-term results.

Intraspinal metalloma causing lumbar stenosis after interbody fusion with cylindrical titanium cages

Intraspinal metallomas are rare. The authors present a case after implantation of two titanium threaded interbody cages at the L4L5 level, without posterior instrumentation. To their knowledge this is the first case due to intervertebral cages. The lack of additional instrumentation had probably allowed the cages to make contact. Subsequently, friction generated wear debris, which led to the formation of a granuloma, responsible for compression of the dural sac. Intraspinal metallosis should be kept in mind as an infrequent cause of delayed neurological symptoms after spinal surgery with metallic instrumentation.

[Lung cancer with bronchial stenosis due to foreign body and Entoameba gingivalis infection]

Oral cavity infection by protozoarian agents may lead to pathologies such as stomatitis and gengivitis. An higher incidence has been reported in immunocompromised patients and in patients with dental disorders. Entoameba gingivalis localizes into oral cavity and in particular into interstitial and interdental spaces. Infection propagation to bronchial or lung parenchyma represents a complication. In this report the Authors, starting from a recently treated case, discuss on the incidence, complications and surgical management of lung infection by Entoameba gingivalis.

[The peculiarities of rat tissue reactions to intraperitoneal implants made out of biodegradable polyhydroxyalkanoates]

The reaction of rat tissues to intraperitoneal placement of implants made out of biodegradable polyhydroxyalkanoates (PHA), was studied at different time points after the operation by the methods of light microscopy. It was found that after intraperitoneal PHA implant placement, the active adhesive process started leading to formation of fibrous adhesions between PHA implants and intestinal loops. When PHA implants were used in the form of films, they became surrounded by a thick fibrous capsule. As a result of PHA implant placement in the form of ultrathin fibers, the extensive foreign body granulomas with perifocal inflammation and sclerosis of surrounding tissues were formed. In these granulomas the polymer fragmentation and phagocytosis by macrophages with formation of giant cells of foreign body occured. It is concluded that PHA implants are not biodegradable and induce tissue reactions similar to those caused by other foreign bodies.

Effects of Alprazolam, Zolpidem and Zopiclone, and of chronic inflammation on peripheral experimental algesia in Wistar rats

In the literature, there are some data which indicate that benzodiazepines and other chemical compounds with the same mechanism of action (Diazepam, Chlordiazepoxide, Lorazepam, Zopiclone, etc.) also have other effects. We investigated the effects of experimental chronic inflammation under the administration of some tranquilizers and hypnotics on peripheral algesia induced in rats by "writhing test". Chronic inflammation was induced by "cotton wool granuloma" technique. The "writhing test" consisted in intraperitoneal injection of an irritant agent (acetic acid 0.0025%, 0.4 mL). The animal reacts with a characteristic stretching behavior called writhing. A writhe is indicated by stretching of the abdomen with simultaneous stretching of at least one hind limb. Then, the animals were placed individually into glass beakers and 5 minutes were allowed to elapse. The rats were then observed for a period of 10 minutes and the number of writhes is recorded for each animal. Three drugs were administered by gastric probe: Alprazolam 1 mg/kg, Zolpidem 10 mg/kg and Zopiclone 10 mg/kg. Alprazolam is a triazolobenzodiazepine derivative used as a tranquilizer. Zolpidem is an imidazopyridine with marked sedative-hypnotic effect and it has the same mechanism of action like benzodiazepines. Zopiclone is a cyclopyrrolone with sedative-hypnotic effect used as hypnotic and acts like benzodiazepines. After that, the animals were sacrificed and the weight of cotton wool granuloma was determined. In the same time, the histopatological aspect of granulomatous inflammation was studied. It was found that experimental proliferative inflammation under the action of these drugs was accompanied by a peripheral analgesic activity in "writhing test". The mechanisms of these effects are not fully elucidated. Some explanations are: they act as agonists or antagonists on algesia and inflammation mediators and they have a stimulating effect on peripheral ω3-benzodiazepine receptors ("peripheral-type" receptors).

[Foreign body granuloma simulating malignant disease in the biliary tract]

Non-absorbable suture materials, such as silk, are able to form foreign body granulomas and stones and consequently their use should be avoided in surgical procedures in the biliary tract. We present the case of a patient who underwent surgery for a probable Klastkin tumor. During the intervention, a 1.5-cm tumor, with firm consistency, extrinsic to the biliary tract was found; the mass was extirpated with no compromise to the biliary tract. Macroscopic examination revealed suture (silk) material. The histopathological report described an inflammatory tumor, composed essentially of macrophages and foreign body giant cells, and identified a suture within the cell cytoplasm. The interest of this case lies in the rarity of this entity, the difficulty of preoperative diagnosis, and its possible confusion with other anatomic and clinical syndromes.

Ileal iterative spontaneous perforation from foreign body granuloma: problems of histopathologic diagnosis

Spontaneous ileal perforation is a very rare cause of peritonitis. It occurs, in most of the cases, as a complication of Crohn's disease or intestinal tuberculosis. We present the case of a 23-year-old female patient with multiple surgical interventions during the last year, for iterative ileal spontaneous perforation with generalized peritonitis of which cause was initially assigned to intestinal tuberculosis. Actual episode of generalized peritonitis was determined once again by an ileal perforation of 5 mm at 70 cm from the ileo-cecal valve situated on a suture scar. Distally, a bowel stricture and a non-complicated Meckel's diverticulum were also noted. We performed an enterectomy including all three aforementioned lesions with end-to-end anastomosis. The histopathologic report revealed granulomatous giant-cellular inflammation in the margins of the perforation. The tuberculous etiology was questioned because of the negativity of the PCR-test and multiple recidives of perforation under specific anti-tuberculous medical therapy. The discovery of some rests of non-resorbable suturing material in a granuloma on an ancient enterorraphy scar in the resected specimen, finally established the cause. The granulomatous giant-cellular inflammation of foreign body is a rare cause of ileal perforation. The histopathologic differential diagnosis is difficult needing correlation with clinical data. Usage of resorbable suture material avoids that risk.

Endoscopic transrostral- transsphenoidal approach to petrous apex cholesterol granuloma: case report

Cholesterol granuloma (CG) of the petrous apex is an inflammatory reaction to the by-products of eroded marrow cavities secondary to chronic obstruction of air cells within the petrous pyramid. We report a case of cholesterol granuloma in the left petrous bone occurring in a 28-year-old woman with an unusual presentation. The woman presented with a 6-month history of intermittent left hemicranial headache and diplopia. CT scan of petrous bone and skull base showed an expansile mass of the left petrous apex. For surgical removal we used the transrostral transsphenoid approach. After surgery, all the symptoms and signs of the patient completely recovered. In this report, the indications and merits of the endoscopic transsphenoidal drainage procedure are illustrated through a case presentation.

A 13-year-old textiloma (gossypiboma) after discectomy for lumbar disc herniation: a case report and review of the literature

BACKGROUND CONTEXT

A paraspinal retained surgical sponge (textiloma) is rare and mostly asymptomatic in chronic cases but can be confused with other soft-tissue masses. Therefore, it is important to be aware of patients with a paraspinal soft-tissue mass with unusual or atypical symptoms.

PURPOSE

A patient with asymptomatic chronic paraspinal textiloma who was operated on 13 years ago for lumbar disc herniation is presented.

STUDY DESIGN

Case report.

METHODS

A patient presented with complaints of back pain radiating to leg and neurogenic claudication. Computed tomography imaging revealed canal stenosis at L3-L5 levels and a soft-tissue mass at the paraspinal muscles of the L5-S1 level.

RESULTS

Surgical treatment was performed for both to excise or obtain biopsy from the soft-tissue mass and to treat spinal stenosis. During the operation, a retained surgical sponge was found and excised completely with fibrous capsule surrounding it and decompression and posterior spinal instrumentation performed without fusion for spinal stenosis with dynamic pedicle screws (Cosmic Pedicle Screw System; Ulrich AG, Germany). Recovery was uneventful, and the patient's stenosis symptoms were resolved soon after surgery.

CONCLUSION

Retained surgical sponges do not show mostly any specific clinical and radiological signs. They should be included in differential diagnoses of soft-tissue masses at the paraspinal region with a history of a previous spinal operation.

Petrous apex aspergillosis as a long-term complication of cholesterol granuloma

Aspergillus infection of the petrous apex is a rare and devastating condition. To date, only two such cases have been reported, which resulted from direct extension of chronic Aspergillus otitis media. We present a case of petrous apex aspergillosis occurring years after surgical drainage of a petrous apex granuloma cyst. Because of the potential lethal nature of this condition, aggressive surgical therapy should be considered early in this illness and may provide the best chance for survival.

Cholesterol granuloma surrounding the endolymphatic sac

We report a unique case of cholesterol granuloma (CG) surrounding the endolymphatic sac (ES). A 49-year-old man presented with the left side of sensorineural hearing loss, tinnitus, and vertigo. Magnetic resonance and computed tomography imaging revealed a CG surrounding the left ES. The patient initially underwent left transmastoid surgical resection of the tumor. At the time of surgery, brown fluid was aspirated from the tumor, but no other tumors were found. Histopathological examination revealed that the tumor contained cholesterol crystals, confirming the diagnosis of CG. At his 12-month postoperative follow-up, there was no evidence of recurrence. We discuss the radiology, pathology, and surgical removal of CGs surrounding ES.

Obstructive jaundice due to a textiloma mimicking a common bile duct stone

A foreign body is a rare cause of obstructive jaundice. We report a 19-year-old woman with jaundice caused by a surgical gauze in the common bile duct (CBD). Four yours earlier, she had undergone a cholecystectomy and drainage for hydatid disease of the liver. Her postoperative course was complicated by a biliary fistula that healed after 50 days. She now presented with obstructive jaundice of 2 weeks' duration. Magnetic resonance cholangiopancreatography (MRCP) showed a signal-void mass, consistent with a CBD stone. Surgical exploration of the CBD revealed a surgical gauze as the cause of the obstruction. To the best of our knowledge, this is the first case of a surgical gauze obstructing the CBD requiring surgical removal.

That's a Wrap

Muslin-induced optochiasmatic arachnoiditis is a rare complication following surgical repair of an intracranial aneurysm but should be suspected in any delayed visual loss after aneurysm repair in which muslin was used. A 52-year-old male underwent clipping and muslin wrapping of a ruptured aneurysm of an anterior communicating artery. Eight months following surgery, the patient developed progressive visual loss, resulting in a bitemporal hemianopsia. Neuroimaging confirmed a suprasellar mass but no recurrent aneurysm. The patient was treated with prednisone and had significant improvement of his vision. Muslin wrapping of aneurysms should probably be avoided in aneurysms near the optic apparatus.

Calcinosis cutis with siliconomas complicated by hypercalcemia

OBJECTIVE

To report a case of extensive calcinosis cutis presumably caused by silicone injections, which was complicated by hypercalcemia.

METHODS

A long-standing case of calcinosis cutis with subsequent development of hypercalcemia is presented, and possible mechanisms for the underlying metabolic dysfunction are discussed.

RESULTS

A 78-year-old woman presented with severe hypercalcemia and was found to have extensive subcutaneous calcifications on the anterior chest wall and abdomen, likely related to previous silicone injections. The hypercalcemia was treated with intravenously administered pamidronate and aggressive rehydration. Resection of the extensive long-standing calcific deposits was not a viable option. The hypercalcemia resolved with treatment, but the patient died of urinary tract sepsis.

CONCLUSION

Extensive calcinosis cutis can result in hypercalcemia, possibly attributable to granulomatous reaction and vitamin D excess.

Mediastinal malignant fibrous histiocytoma developing from a foreign body granuloma

A patient with mediastinal malignant fibrous histiocytoma (MFH) apparently developing from a foreign body granuloma is reported. A 72-year-old man was admitted to our hospital complaining of generalized fatigue and palpitations. He had undergone surgery for pulmonary tuberculosis 46 years previously. Radiography and computed tomography of the chest showed a round 5-cm mass with marginal calcification in the right side of the anterior mediastinum. The mass was resected completely via median sternotomy. Intraoperative diagnosis of foreign body granuloma was made, based on gauze fragments found in the mass and intraoperative pathologic findings suggesting benign granulation tissue. The postoperative histopathologic diagnosis was myxoid MFH. To our knowledge, mediastinal MFH developing from a foreign body granuloma has not been reported previously.

Pneumomediastinum due to tracheal foreign body granuloma

Primary tracheal masses are rare. Secondary masses of the trachea are commonly foreign body granuloma, intubation granuloma or viral granuloma. The differential diagnoses given in such cases include both benign and malignant lesions. The otolaryngologist is often asked to perform a biopsy of the lesion to arrive at a diagnosis. However, even malignant processes can cause a granulomatous reaction. The timely diagnosis of tracheal masses depends upon maintaining a high index of suspicion. A rare case of tracheal granuloma leading to pneumomediastinum in a 53-year-old female is presented. The clinical features, investigations and treatment are detailed. The tracheal granuloma was managed by excision through bronchoscopy and the pneumomediastinum was managed conservatively.

Massive prolapse of the urethral mucosa following periurethral injection of calcium hydroxylapatite for stress urinary incontinence

The injection of bulking agents into the urethral submucosa is designed to create artificial urethral cushions that can improve urethral coaptation and hence restore continence. Ideally, a urethral bulking agent should be non-immunogenic and biocompatible, leading to minimal inflammatory and fibrotic response. The authors present a case report of a granulomatous reaction leading to urethral prolapse, 3 months after the transurethral injection of calcium hydroxylapatite. To our knowledge, this is the first granulomatous reaction described after calcium hydroxylapatite injection.

Short course of prednisolone in patients with solitary cysticercus granuloma: a double blind placebo controlled study

The study was conducted to confirm the role of a short course of oral corticosteroids in patients with solitary cysticercus granuloma with seizures by a double-blind placebo-controlled study. In an open-label trial we, in past, had demonstrated a beneficial role of prednisolone. A short course of prednisolone helped in early resolution of solitary cysticercus granuloma. In this double-blind placebo-controlled randomized study, 60 patients with new-onset seizures and a single enhancing computed tomography (CT)-detected lesion of cysticercosis were randomly divided in two groups to receive either anti-epileptic monotherapy with prednisolone (n=30) or anti-epileptic monotherapy along with placebo (n=30). The patients received prednisolone, 1mg/kg/day for 10 days, followed by tapering over next 4 days. None of the patients received albendazole therapy. The patients were followed up monthly, at least for 9 months. A repeat CT scan was performed after 6 months. The data were analysed by chi-square test. The majority of patients were young. Simple partial seizure, with or without secondary generalization, was the commonest seizure type encountered. Follow-up CT scans at 6 months demonstrated non-significantly better response for prednisolone treated patients. In prednisolone group the lesion disappeared in 52% of patients and in 48% patients who received placebo. However, a significantly lesser number of prednisolone treated patients (n=12%) than controls (n=48%), had seizure recurrence. Our study suggests that short-term prednisolone therapy may not help in rapid resolution of solitary cysticercus granuloma, however, prednisolone therapy improves seizure-related prognosis.

Keratoacanthoma centrifugum marginatum accompanied by extensive granulomatous foreign body reaction

We describe a 58-year-old woman with a 4-year history of papular lesions with a partly verruciform appearance on the eyelids and the adjacent areas of the nose. The lesions progressed slowly but constantly into the surrounding areas with central scarring. Histopathology showed epidermal endophytic proliferations under a pronounced hyperparakeratosis. In the adjacent dermis a lymphohistiocytic infiltrate with giant cells of the foreign-body-reaction type was seen in close contact to extracellular keratin deposits. Although some cytopathological signs typical for viropathic effects were observed, no human papilloma virus-DNA was detected within the lesions by polymerase chain reaction. According to the histological picture and the clinical course we diagnosed a keratoacanthoma centrifugum marginatum. We present this case because of the strong granulomatous foreign body reaction which might complicate the diagnosis and has not been described for this keratoacanthoma variant so far.

A cholesterol-containing foreign body granuloma presenting as an inter-metatarsal bursa

A 68-year-old man presented with progressive forefoot swelling which coincided with the onset of type 2 diabetes mellitus. Imaging revealed a cystic inter-metatarsal mass containing two foreign bodies, which had been present for many years. Following aspiration of the mass, cholesterol crystals were observed on polarised microscopy. It is postulated that the development of diabetes triggered the shedding of cholesterol crystals around a long-standing quiescent foreign body granuloma.

Scalp paraffinoma underlying squamous cell carcinoma

We report the case of an 84-year-old man with multiple squamous cell carcinomas located on his bald scalp, arising in association with underlying paraffinoma. Histologically, poorly differentiated, acantholytic squamous cell carcinomas were located above characteristic pseudocystic spaces. Carcinomas have been reported in association with penile and breast paraffinomas, but we are unaware of any reports of squamous cell carcinoma arising over a scalp paraffinoma.

Cholesterol granulomas in antrochoanal polyps: a clinicopathologic study

The purpose of this study was to investigate antrochoanal polyps with cholesterol granuloma (CG), which is a granulomatous reaction to cholesterol crystals that has been precipitated in the tissue. It is usually associated with chronic middle ear disease, common in the mastoid air cells, less common in the orbit and rarely found in the paranasal sinuses. The aim of this study was to analyze the etiology and pathological findings of antrochoanal polyps associated with cholesterol granuloma. This is a retrospective study of five cases of antrochoanal polyp with cholesterol granuloma, (four males and one female between 15 and 77 years of age) who presented with nasal obstruction, rhinorhea and snoring. The cases were clinically and histologically reviewed. Four patients were treated endoscopically and one by intranasal polypectomy without endoscope. There was no recurrence during the follow-up between 24 to 36 months (mean 31.2 months). Five uncommon cases with antrochoanal polyp with cholesterol granuloma are presented. The cholesterol granulomas consist of fibrous granulation tissue containing cholesterol crystals with surrounding foreign body giant cells. The pathogenesis of antrochoanal polyp with cholesterol granuloma is unclear, and further investigations are needed.

Granulomatous diseases of the oral tissues: differential diagnosis and update

Because of the relatively nonspecific clinical findings associated with a variety of granulomatous diseases, a microscopic diagnosis of granulomatous inflammation often presents a diagnostic dilemma for the clinician. The most common differential diagnosis includes foreign body reactions, infection, Crohn's disease, sarcoidosis, and orofacial granulomatosis. However, a variety of other conditions may be associated with granuloma formation. Often an extensive clinical, microscopic, and laboratory evaluation may be required to identify the source of the granulomatous inflammation. This article highlights the origin, clinical manifestations, current diagnostic modalities, and treatment of specific granulomatous diseases that may be encountered in clinical practice.

[Fibular nerve compression due to an unusual cause. A case report]

There are many factors causing a compression of the fibular nerve accompanied by a loss of function. We describe an unknown cause: a chronic low-grade infection after implantation of a knee endoprosthesis. Perforation of the capsule of the knee joint followed by discharge of polyethylene particles originating from the endoprosthesis. A granuloma developed which resulted in a compression of the peroneal nerve with sensomotor disabilities. Preoperatively we were not able to define the dignity of the tumour. Neurolysis was performed followed by excision of the tumour. The infection was treated by long term antibiotics without removal of the endoprosthesis. Histological examination revealed the definitive diagnosis.

Prednisolone-responsive headache in patients with solitary cysticercus granuloma and seizures

BACKGROUND

Solitary cysticercus granuloma is the commonest imaging abnormality in Indian patients with new-onset seizures. Few patients, in addition, complain of disabling headache.

OBJECTIVE

To report our experience of 16 patients with new-onset headache, seizures, and solitary cysticercus granuloma.

METHODS

Sixteen consecutive patients, who had moderate to severe new-onset headache and fulfilled the diagnostic criteria of solitary cysticercus granuloma, were included in the study. The inclusion criteria were: occurrence of seizures, minimal or no neurologic deficit, absence of papilledema, no evidence of any systemic disorder, and computed tomography showing a single ring/disk-enhancing lesion of <20 mm in diameter. Patients received antiepileptic monotherapy, oral analgesics, and prednisolone (1.5 mg/kg/day for 7 days). Prednisolone was then tapered over the next 7 days. Patients were followed for 6 months. Follow-up computed tomography was performed after 2 months; in all 16 patients, the scans showed complete disappearance of the lesion.

RESULTS

After 14 days (at first follow-up), all patients reported significant improvement in headache. Follow-up after 2 months revealed that all patients were headache-free. None of the patients reported any recurrence of headache.

CONCLUSION

This open-label study suggests the effectiveness of prednisolone for disabling headache in Indian patients with solitary cysticercus granuloma and seizures. There is a need, however, for more scientifically rigorous studies for further confirmation of our results.

A retrospective study on cholesteatoma otitis media coexisting with cholesterol granuloma

To investigate the etiology and pathogenesis of cholesteatoma otitis media accompanied by cholesterol granuloma and the relationship between cholesteatoma and cholesterol granuloma, 63 cases of middle ear cholesterol granuloma treated in our hospital during the period from March 1988 to May 2000 were retrospectively reviewed. All cases were surgically and pathologically verified. 15 cases of cholesteatoma coexisting with cholesterol granuloma were found among the 63 patients. All 15 cases had a long-term history of otitis media, such as otorrhea (sanguine purulent otorrhea and bloody otorrhea in 8 cases) and perforation of the eardrum (perforation of pars flaccida in 8 cases). Temporal bone CT scans showed cholesteatoma in 11 cases. All patients were treated surgically, and cholesteatoma and cholesterol granuloma were found coexisting alternately, the latter lying mainly in the tympanic antrum, attic and mastoid air cells. Chocolate-colored mucus was accumulated in well-developed mastoid air cells, and glistening dotty cholesterol crystals were also found. In most cases, enlarged aditus, destruction of lateral attic wall, erosion of ossicular chain, exposure of horizontal segment of facial nerve and tegmen of attic were observed. Occlusion of Eustachian tube was noted in 6 cases, and occlusion of tympanic isthmus was revealed in all cases. A post-operative dry ear was achieved in all patients, and hearing improvement was achieved in all 12 cases following tympanoplasty. Cholesteatoma and cholesterol granuloma in middle ear may share a common pathophysiological etiology: occlusion of ventilation and disturbance of drainage. The diagnosis should be considered when patients presented with chronic otitis media with bloody otorrhea. CT and magnetic resonance imaging are useful for the diagnosis before operation. The surgical approach depends on the location, extension and severity of the lesion. The purpose of surgery is to remove the lesion and create an adequate drainage.

Invasive Middle Ear Cholesterol Granuloma Involving the Basal Turn of the Cochlea With Profound Sensorineural Hearing Loss

STUDY DESIGN

A retrospective surgical case review.

SETTING

A tertiary-care, university teaching hospital.

PATIENTS

The authors describe a unique case operated on for a middle ear cholesterol granuloma, which had invaded the cochlea and vestibule causing profound sensorineural deafness.

INTERVENTIONS

Extended radical mastoidectomy and labyrinthectomy with musculofascial seal.

RESULTS

Successful postoperative outcome with no recurrence seen after 2 years of follow up.

CONCLUSION

To the authors' knowledge, this is the first reported case of a primary middle ear cholesterol granuloma with direct invasion into the cochlea. Such invasion of the otic capsule by cholesterol granulomas is rare and presents a diagnostic challenge to the attending otologist and radiologist. Salient points of the case history, pathogenesis, imaging studies, histopathology, and management are presented with a review of the current literature.

Abscess formation after lip augmentation with silicone: Case report

This paper describes the development of an abscess after injection of an alloplastic preparation (silicone) for enhancement of the lower lip. The 56-year-old woman presented with a painful swelling of her lower lip which was incised. Pus drained from the incision. A biopsy was taken. Histology revealed homogeneous foreign body inclusions (silicone) with fibrosis, chronic inflammation and multinuclear giant cells. Healing was uneventful with little deformation of the lower lip. Since the number of persons seeking aesthetic lip augmentation is increasing, oral surgeons and dentists should be familiar with adverse effects to filling agents.

Cutaneous reactions in patients with solitary cysticercus granuloma on phenytoin sodium

Several medical conditions are believed to be associated with an increased risk of cutaneous adverse reactions to anti-epileptic drugs. The aim of this study was to study the frequency and nature of cutaneous reactions in a cohort of patients being treated with phenytoin sodium for seizures, who were divided into those with a solitary cysticercus granuloma (SCG) and those with a condition other than SCG, to determine if the presence of SCG increases the risk of cutaneous adverse reaction to phenytoin. A cohort of 117, consecutively begun on treatment with phenytoin for seizure control, were followed up prospectively for the development of cutaneous reactions. There were 63 patients with SCG upon imaging and 54 patients to whom phenytoin was administered for seizures due to causes other than SCG or multiple neurocysticercosis. Cutaneous reactions were significantly more common (p = 0.02) in patients with SCG (9/63 patients; 14.3%) than in controls (2/54 patients; 3.7%). The spectrum of skin reactions in patients with SCG included benign skin rash (n = 3), anticonvulsant hypersensitivity syndrome (n = 4), Stevens-Johnson syndrome (n = 1), and urticaria (n = 1). Individuals with seizures due to SCG have a high incidence of cutaneous adverse reactions to phenytoin. This fact should be kept in mind when initiating them on treatment with this anti-epileptic drug.

Bone wax as a cause of a foreign body granuloma in a cranial defect: a case report

Bone wax was used to stop bleeding of the diploic vessels after harvesting cranial bone for reconstruction of an orbital floor defect. After five months a fistula in the overlying skin of the donor site appeared and was eventually surgically explored. Remnants of bone wax and surrounding inflammatory tissue were removed and the fistula was excised. Histological examination revealed a foreign body granuloma. The use of bone wax and possible alternative local haemostatic agents and their complications are discussed.

Foreign body granuloma: a new manifestation of immune restoration syndrome

BACKGROUND

People with human immunodeficiency virus may experience an immune restoration syndrome during the lymphocyte recovery period following effective highly active antiretroviral therapy. In this syndrome, antigens that previously were ignored by the immune system now induce an exaggerated response with obvious clinical effects. Most cases have been associated with infectious agents such as cytomegalovirus or mycobacterium avium intracellulare. However, the sudden onset of sarcoidal granulomatous reactions have also been described in this setting.

OBJECTIVE

We report a 66-year-old HIV-positive man who presented with exacerbation of multiple foreign body granulomas decades after the original injuries. The presentation coincided with a significant rise in CD4 count after beginning highly active antiretroviral therapy.

CONCLUSION

We propose that this case demonstrates another manifestation of the immune restoration syndrome and postulate that an uncontrolled Th1 response is the causative mechanism.

Granulomatosis associated to porcelain wear debris

PURPOSE

To determine the origin of a cryptogenic granulomatosis using an innovative diagnosis technique.

MATERIALS AND METHODS

A patient affected by fever of unknown origin for 9 years was diagnosed with colestasis and acute renal failure with pathological evidence, in parenchimal samples, of granulomatosis of unknown origin. New scanning electron microscopic observations on the biopsy samples from the liver and the kidney and x-ray elemental microanalyses showed the presence of debris made of silicone, aluminum, sodium and potassium, and aluminum-silicate similar to dental porcelain. The same SEM and x-ray analyses were carried out on the patient's worn porcelain dental bridges.

RESULTS

A correlation was demonstrated between wear debris of porcelain and the cryptogenic granulomatosis, which lead to a different therapeutic approach and the removal of the origin of the debris; this stabilized the situation and caused an improvement of the disease. The results indicated that a material can be biocompatible when used in a solid bulk, but this property can be lost when it is degraded into small particles.

Dissecting popliteal cyst resulting from a fragmented, dislodged metal part of the patellar component after total knee arthroplasty

Dissecting popliteal cyst is an uncommon complication after total knee arthroplasty, occurring mainly as a result of either rheumatoid arthritis or a malfunctioning knee prosthesis. Its association with a failed metal-backed patellar component has not been reported since the introduction of the resurfacing of the patella with this kind of design in 1980. We present a case of a late fracture-dislocation of the metal part of the patellar component that migrated to the posterior popliteal fossa, resulting in a cystic mass formation caused by a foreign body granuloma. The patient was treated successfully with a 2-stage operation: first, revision of the total knee arthroplasty and, second, excision of the cyst. The patient had a pain-free functional knee 7 years after surgery, with no recurrence of the symptoms or the popliteal cyst.