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No.1. Vol.29. Januari – Juni 2005
A RARE CASE OF
GENERALIZED
GRANULOMA
ANNULARE THAT
RESEMBLE WITH
ERYTHEMA ANNULARE
CENTRIFUGUM
Fitra Deny*, Sri Lestari,KS*,
Isramiharti*, Zainal H*, Salmiah A **
*Bagian Ilmu Kulit & Kelamin FK
UNAND / RS Dr. M. Djamil Padang
**Bagian Patologi Anatomi FK
UNAND/RS. Dr. M. Djamil Padang
Abstract
A case of granuloma annulare
of 16- year- old is reported. The
patient had numerous annular plagues
that coalesce form arcuate or
polycyclic pattern with raised border
since 1 month ago with unknown
causes. Histopathology examination
revealed perivascular lymphocytes
infiltrate, degenerated of collagen,
interstitial and slight palisaded
lymphohistiocytes arrangements in
dermis.
Granuloma annulare (GA) is a
self-limited and uncommon cutaneous
disease. Clinically mimicking with
some of dermatoses with annular
configuration. The chief aid in the
LAPORAN KASUS
diagnosis of granuloma annulare is
biopsy.
Key word : granuloma annulare,
palisaded
lympohistiocytes
arrangements
ABSTRACT
A case of granuloma annulare
of 16-year-old is reported. The patient
had numerous annular plagues that
coalesce form arcuate or polycyclic
pattern with raised border since 1
month ago with unknown causes.
Histopathology examination revealed
perivascular lymphocytes infiltrate,
degenerated of collagen, interstitial and
slight palisaded lymphohistiocytes
arrangements in dermis.
Granuloma annulare (GA) is a selflimited and uncommon cutaneous
disease. Clinically mimicking with
some of dermatoses with annular
configuration. The chief aid in the
diagnosis of granuloma annulare is
biopsy.
Key words : granuloma annulare,
palisaded
lympohistiocytes
arrangements
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INTRODUCTION
Granuloma Annulare (GA) is a
benign, usually self-limited dermatoses
of unknown etiology, which clinical
characteristics with annular plaques to
form arciform configuration with
raised border.(1-4) GA is an uncommon
cutaneous disease.(4,5) GA is most
common in children and young
adults.(3) Trauma, insect bite reactions,
tuberculin testing, sun exposure,
PUVA therapy and viral infections
have all been proposed as inciting
factors.(6)
GA can present with clinical
variants are : Localized GA with
characteristics most common appears
in dorsal of hand and feet with solitary
lesion. In generalized GA usually
appears more than ten lesions, involve
the
trunk
and
the
lesions
predominantly
on
extensor
of
extremities, symmetry. In subcutaneous GA, lesions usually are
nodules, may be solitary or multiple
lesions, usually mith diabetes or
abnormal glucose tolerance. In
perforating GA, the lesions appears as
small
papules
with
central
umbilication, plugs and crusts.(1,2,4,7)
The pathogenesis of granuloma
annulare
is
obscure.
Proposed
pathogenic mechanisms include cell
mediated immunity (type IV), immune
complex vasculitis and abnormality of
tissue monocytes but none has
convincing supporting.(4) A viral or
vascular etiology are among many
that have been suggested over the
years.(8)
Generally,
patients
with
granuloma annulare are in good health.
A relationship of granuloma annulare
to the other diseases like diabetes
mellitus,
necrobiosis
lipoidica
diabeticorum and rhemathoid nodules
has been widely discussed, but no
firmly established.(2) The clinical
features presented firm, smooth, shiny
dermal papules that often coalesce to
form annular plaques with raised
erythematous borders, 1-5 cm,
painless, skin coloured–violaceous,
soliter or multiple, dome shaped,
annular arciform.(1,2,4) Lesions most
commonly manifest on the dorsal
surfaces of the feet, hand and fingers
and on the extensor aspects of the arms
and legs.(4)
The chief aid in the diagnosis of
granuloma annulare is biopsy.(1,9) The
results of blood and urinalysis tests are
usually
normal.(1)
The
basic
histopatology picture is characterized
by the presence in the dermis of small
or large foci collagen degeneration
surrounded by a lymphohistiocytic
infltrate composed mostly histiocytes
in a palisading arrangement.(1,2,10)
mucin deposition. The mucinous
material can be identified by special
stains, colloidal iron, toluidine blue,
etc.(1,2,4,10)
Differential diagnosis of annular
lesions are dermatophytosis, erythema
annulare centrifugum, porokeratosis
Mibelli sarcoidosis, annular lichen
planus, other palisading granulomas
(necrobiosis lipoidica, rheumatoid
nodule,
actinic
ganuloma).(1.2,4)
Erythema Annulare Centrigugum
(ECA) is eruption with
annular
erythematous plagues with trailing
scale that form arciform or polycyclic
in configuration with raised borders.
Histopathology revealed coat-sleeves
perivascular lymphocytes infiltrate.
(11,12)
Porokeratosis Mibelli uncommon
disease that may occur any where on
the body with characteristic lesion is
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annular plaques with well-demarcated
raised hyperkeratotic border with
central atrophy.(13)
Although the disease usually selflimited, clinicians have use a wide
array of treatment method to hasten
resolution,
these
include
:
glucocorticoid topical an intralesions,
tacrolimus
ointment,
imiquimod
cream, psoralen plus PUVA, narrow
band UVB,
isotretinoin, dapson,
chloroquin, nicotinamide, niacinamide,
vitamine E.(2, 4,14)
CASE
A 16-year-old of adolescent boy
came to the Dermato-Venereology
Department out patient Dr. M. Djamil
Hospital on March 31th, 2005 with
numerous annular redish-violaceous
patches scattered at over the arms
since 1 month ago.
Present illness history
There were sharply demarcated
redish-violaceous patches with raised
irregular border scattered at both of
arms since 1 month ago.
Initially, the patches were only
insect bite lesions-like on his left upper
arm and later became enlarged and
numerous then spreaded fast to both
of the arms and lateral chests. Some
times he felt itchy but it wasnot
intents. He got some medicines from
phycisians, but no improvements. His
medicines were anti histamine and
ointment (he forgot what name of
ointment). There was no history of
taken of medicines, regarding diets,
fever, trauma, excessive sun exposure,
weight loss, hepatitis history and
complaints associated with his joints
before. There were no history of
urticaria, allergic of food before.
There were no family suffered
from this disease, diabetic history,
others cancers, and
rheumatoid
disease.
General examinations were in
normal limits.
Dermatologycal state :
On the lateral chests, both of arms,
predominantly on the extensor surface
revealed numerous lesions which
bilaterally disseminated distribution,
The lesions varied in shapes, annular,
ellips, and some may convert into
polycyclic or arcuate forms. The
lesions consisted of erythematousbrownish papules, well-demarcated
annular redish-violaceous
plaques
with raised borders that some
coalescence form arcuate pattern. This
borders consisted of violeaceous
papules that arranged a treadlike
groove. The lesions varied in sizes,
millier, lenticular to plaque with the
central pink- violaceouos coloured. On
some of patches revealed scales. The
surrounding tissue of lesions were
normal
Mucous membranes were in
normal limits.
Test of sensibility
There were no
anesthesia.
Majalah Kedokteran Andalas No. 1. Vol.29. Januari – Juni 2005
hypoesthesia
or
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Suggestion :
Histopathology examination
Blood and urynalysis examination
Skin scraping with KOH 10%
Laboratory finding
Blood examination :
Hb
: 12,3 gr%.
Leucocyte
: 8300/mm3.
ESR
: 21/1.
Ht
:37%.
Thrombocyte : 434.000/mm3.
Diff Count
: 0/2/3/68/26/1
Sugar blood : 98
SGPT
: 16.
SGOT
: 15.
Rheumatoid factor
: Negative.
Urinalysis tests
Protein
:Negative.
Reduction
:Negative.
Leucocyte
:0-4/mm2.
Erythrocyte :0-1/ mm2.
Result skin scrapping with KOH
10% examination :
Hypha or spora were negative
Working diagnosis :
Granuloma annulare
Differensial diagnosis :
 Erythema
annulare
centrifugum.
 Porokeratosis Mibelli.
 Annular lichen planus.
 Tinea corporis.
Result
of
histopathology
examination
Epidermis
Focal parakeratosis, slightly acanthosis
Dermis
:
Perivascular
mono
nuclear
infiltrate
with
slight
collagen
degeneration of dermis and some loose
connective tissue area. Discrete foci of
lymphohistiocytes within the dermis in
slight
palisaded
arrangement,
epitheloid cells.
Subcutaneous There were no
abnormality. This features supported
to granuloma annulare
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Suggestion :
specific staining for mucin
Treatment :
General treatment
:
- Explaination to patient that this
- Topical : flucinolon cr 5%
Prognosis
Quo ad vitam
Bonam
Quo ad sanam
dubia ad bonam
Quo ad cosmeticum
Bonam
Quo ad fungsionam
Diagnosis
Granuloma annulare
:
:
:
: Bonam
DISCUSSION
GA is uncommon dermatosis
whose frequency in the general
population is unknown. In Dr. M.
Djamil Hospital Padang, this is first
case that has been reported. The type
of GA was generalized GA, because of
we found more than ten lesions. Only
15% of GA with this type.
Diagnosis of this disease based on :
- Mildly pruritic lesions
and
usually occur in young adult
- Spontaneous remmision
- Lesions consisted of papules that
coalescence to form annular
plaques with raised borders.
- Histopathology
examination :
characteristic appearances of this
disease were mucinous areas that
be surrounded by palisaded
lympho histiocytes or histiocytes
present just an interstitial pattern,
perivascular lymphocytes infiltrate,
collagen degeneration.
Differential diagnosis was
Erythema Annular Centrifugum (ECA)
or erythema gyratum perstans. Signs
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and symptoms of this disease included
:
- History of hypersensitivity
- mildly pruritus and can occur any
age.
- Spontaheous remmision.
- Lesions begin as erythematous
macules or urticarial papules and
enlarged to form arciform or
polycyclic in configuration with
raised borders and central
clearing with trailing scale.
- Histopathology revealed focal
spongiosis
and
focal
parakeratosis, ‘coat-sleeves-like’
perivascular
lymphocytic
infiltrate.
In this patient, clinically we found
lesions consisted of papules that
coalescence to annular plaques with
scale, but not trailing scale. The
borders of the lesions were brownish,
in ECA usually erythematous.
Histopathology finding revealed slight
spongiosis,
focal
parakeratosis,
perivascular lymphocytes infiltrate,
slight palisaded lymphohistiocytes
array, degenerated of collagen.
It may because of course of disease
and process of preparating staining, we
could not identify mucin deposition. It
can be identified with specific staining
for mucinous material such as alcian
blue or colloidal iron.
We did not found the palisaded
histiocytes. In literatures mentions that
we could find the features of GA with
unpalisaded, slight palisaded and well
palisaded histiocytes that surrounding
the degeneration areas, occasionally
sections will not reveal increased
mucin particularly those lacking a
palisaded arrangement of histiocytes.
On rare occasions there are
aggregations
of
epitheliod
histiocytes.(10)
Because of this reason. Diagnosis of
this patient tends to granuloma
annulare. But by mucin preparation
staining it will support to diagnosis.
Other differential diagnosis
were porokeratosis Mibelli and annular
lichen planus. Porokeratosis Mibelli
based on clinical appearances will be
found annular plaques with welldemarcated raised hyperkeratotic
borders contain a threadlike-groove
much like dike split by a longitudinal
furrow. Histopathology examination
will be found cornoid lamella (keratinfilled invagination).
In annular lichen planus
included intent pruritus, small papules
with network of white lines and
histopathologically revealed a bandlike dermal lymphocytic infiltrate and
saw-tooth appearances as a hallmark.
By histo-pathology we could exclude
both of this diseases.
Because of the etiology is
unknown, its difficult to give the
suitable
therapy.
By
topical
corticosteroid, there were significant
improvements in 4 weeks. Prognosis
of this disease was good with
spontaneous remmision but it can be
exacerbation.
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K, Austen KF, Goldsmith LA,
Katz SI, Fitzpatrick TB, eds.
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