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KMID : 0363220170550070478
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Korean Journal of Dermatology
2017 Volume.55 No. 7 p.478 ~ p.480
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Multiple Subcutaneous Granuloma Annulare Lesions Mimicking Erythema Nodosum Observed on the Lower Extremities in a 4-year-old Boy
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Hyun Dong-Ju
Kim Dong-Hyun
Yoon Moon-Soo
Lee Hee-Jung
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Abstract
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A 4-year-old boy presented to our clinic with a weeklong history of erythematous to brownish nodules on both shins with a known history of acute respiratory tract infection symptoms a month prior to presentation. He denied any history of drug administration or underlying medical conditions. Physical examination revealed multiple erythematous to brownish firm non-tender nodules of various sizes (greater than 20 in number) on his lower extremities (Fig. 1). Histopathology showed multiple histiocytic palisades around areas of necrobiosis and mucin deposition throughout the deep dermis and down to the subcutaneous layer (Fig. 2). Laboratory evaluation did not reveal any abnormalities including assessment of a complete blood count, antistreptolysin O titer, erythrocyte sedimentation rate, and a rheumatoid factor level. He was diagnosed as having subcutaneous granuloma annulare (SGA), and his lesions showed marked improvement after 2 months of topical tacrolimus treatment.
Granuloma annulare (GA) is a common inflammatory skin disease that is self-limiting in nature and shows several distinct subtypes: localized, generalized, perforating, patch, and subcutaneous (SGA). SGA is a rare variant seen predominantly in children and usually presents as a single or a couple of firm non-tender nodules on the extremities1,2. Although there have been several reports of multiple SGA lesions noted in patients, those lesions reported in previous cases have usually been limited to 6 or less and only two case reports have described patients with multiple SGA lesions showing more than 10 lesions3,4. In these cases, however, the lesions were all confined to the scalp, and there are no reports of SGA observed on the extremities with numerous lesions, as was found in our case.
Differential diagnosis should include erythema nodosum due to its similar clinical presentation. However, in contrast to erythema nodosum, the lesions observed in our case were not associated with tenderness on physical examination. Histologically, we found abundant mucin deposition, necrobiosis, and histiocytic palisades, which are typical features observed in those with GA and rare findings in those with erythema nodosum. Histological differential diagnosis must include differentiation between SGA and a rheumatoid nodule. Histological features such as abundant mucin deposition, less stromal fibrosis, and rare foreign-body giant cells, which are typically seen in SGA and were also found in our case, help differentiate this condition from a rheumatoid nodule4. Additional features to distinguish between the two disease entities are clinical features of rheumatoid nodules, such as their usual occurrence over pressure points, or a high seropositive rate.
GA is often self-limited and may not need aggressive treatment. Although various treatments are reported to be effective, there are no well-established studies to verify the validity of these treatment strategies. Topical immune modulators are frequently used for treatment of localized forms of GA1,5. As was described in previously reported cases, our patient showed marked improvement after application of topical tacrolimus for 2 months; however, the possibility of spontaneous resolution could not be excluded.
We report a rare case of SGA with multiple lesions on the lower extremities, which is a rare clinical presentation of this condition, mimicking erythema nodosum.
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KEYWORD
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Erythema nodosum, Granuloma annulare, Lower extremity
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