73 year-old woman with wide-spread plaques

The patient is a 73-year-old woman with a two month history of an eruption that began on the buttocks and thighs. It has spread to the arms. The clinical picture was not diagnostic, so biopsies have been done.

She is in her usual state of health.  There is no history of systemic illness. Her medications include: amlodopine, metooprolol, ASA, all for a number of years.  She had a tetanus booster a week before the onset of the rash.

I thought this would probably be indolent but she has has developed marked pruritus.  Because of her symptoms she was treated with fluocinolnide oinment. This had no effect. Doxycycline was not tolerated due to GI symptoms.

Laboratory studies were done. CBC and chemistries were within normal limits. Her Lyme tighter was negative.

Examination shows large plaques on the buttocks and thighs that they are now appearing on the arms. The remainder of the examination is unremarkable. 

Clinical Images:

Pathology:

Dermal interstitial proliferation of histiocytes with focally increased dermal mucin and increased dermal mucin.  Individual collagen fibers are circumferentially ringed with histiocytes.  The dermatopathologist  feels this is either interstitial granuloma annulare or interstitial granulomatous dermatitis.  Images courtesy of Lynne Goldberg, Boston University Skin Path.

 Diagnosis: Interstitial granuloma annulare versus interstitial granulomatous dermatitis.
There is one reference on PubMed to granuloma annulare following DT vaccination.

Reference:
1. A case of granuloma annulare in a child following tetanus and diphtheria toxoid vaccination.

Baskan EB, et. al. J Eur Acad Dermatol Venereol. 2005 Sep;19(5):639-40

What are your thoughts?

Annular Lesions in a 50 yo woman

This image was sent by Dr. Yogesh Jain from India for diagnostic suggestions.
The only history provided was that the process is present on the hands and feet and has been ongoing for 25 years. The lesions regress after a number of months.

Other than a variant of granuloma annulare or elastosis perforans serpiginosa, what are your thoughts?

Biopsy is important but so is the dermatopathologist who reads it.

34 yo woman with micropapules

The patient is a 34 yo woman with a 1 year history of a slightly pruritic eruption on her upper arms, elbows, mid back.  Her health is good and she takes no meds p.o.  She commutes between Seoul, New York City and Paris for her work in fashion.

The lesions are symmetrically placed in these areas.

Pathology:  Two 3 mm punch biopsies taken.

There is an interstitial proliferation of lymphocytes and histiocytes forming granulomas with focally increased dermal mucin and central necrobiosis, and with islands of intervening normal dermal collagen and a mild superficial and mid perivascular lymphocytic infiltrate with occasional plasma cells. These findings support the histologic diagnosis of granuloma annulare.

Diagnosis: Granuloma annulare

The clinical picture is unusual, but in retrospect, it fits.  Perhaps, this is an example of generalized G.a.  The patient is otherwise healthy but we have no recent lab tests.  It may be prudent to obtain A1c, chemistry and lipid profile.

What are your thoughts?

Reference: 
1. Remission of generalized erythematous granuloma annulare after improvement of hyperlipidemia and review of the Japanese literature.
Watanabe S et.a.l  Dermatol Pract Concept. 2014 Jan 31;4(1):97-100.  Free Full Text Online

Interstitial Granulomatous Dermatitis in a Child

Abstract: 8 year-old girl with a one week history of a symmetrical eruption
This patient is presented with permission from her parent.

HPI:  The patient is an otherwise healthy 8 year old girl with a one week history of a mildly pruritic eruption;  No antecedent illnesses.  She has molluscum diagnosed in other areas a few months ago.

O/E:  On May 1, 2012, she had discrete and confluent erythematous papules on both thighs and to a lesser extent on both elbows and abdomen.  There was marked cervical lymphadenopathy (present, by history, for years).  By May 3rd, the lesions had enlarged and coalesced into symmetrical plaques on the thighs, buttocks,  and lower extremities.

Clinical Photos (May 3, 2012)

Labs:  CBC, UA normal

Pathology: There is a superficial and mid-perivascular and interstitial lymphocytic infiltrate with neutrophils and rare eosinophils. (Photomicrographs courtesy of Dr. Marjan Mirzabeigi, Dermatopathology, Boston University Department of Dermatology)

 
 

Diagnosis:  Clinically, I considered a viral exanthem or the urticarial phase of Henoch-Schoenlein Purpura.  Histologically, the suggestions were interstitial granulomatous dermatitis (IGD) or an interstitial variant of granuloma granuloma annulare.

Course:  Over the course of two weeks, the lesions completely resolved.  No therapy had been offered.  The child remains well at this time and is at full activity.

Questions:  Have you seen similar cases?  What are your thoughts about "interstitial granulomatous dermatitis."  It is only rarely seen.

Discussion: IGD is a relatively newly described disorder and not much is known about etiology or course.  There may be short-lived variants such as this that are reactions to viral illnesses, drugs or other causes.  Case reports such as this may help to define such rare disorders.

Reference:
Interstitial granulomatous dermatitis
Hillary Johnson MD PhD, Stephanie Mengden MD, Ronald R Brancaccio MD 
Dermatology Online Journal 14 (5): 18 Free Full Text.