Granuloma annulare on ultrasound: a diagnosis to consider in pediatric skin lesions.

BACKGROUND: Granuloma annulare (GA) is a rare, benign, inflammatory, self-limited, granulomatous dermatosis that affects children and young adults. The most frequent clinical form is localized GA. Deep GA generally presents as painless palpable subcutaneous nodules in the lower extremities, buttocks, hands and scalp. They may have a fast-growing firm subcutaneous mass presentation, mimicking a malignant lesion which requires an imaging evaluation. Diagnosis of deep GA can be more difficult and imaging evaluation is frequently performed, ultrasound being one of the techniques used. OBJECTIVE: To describe the US characteristics of GA in a pediatric series. MATERIALS AND METHOD: Descriptive, retrospective, 14-year study of all pediatrics GA cases. RESULTS: Twelve pediatric cases with GA. 66% females. The lesions were mainly distributed in the extremities: 50% in the lower extremities and 42% in the upper extremities, mostly with multiple lesions. A total of 45 lesions were analyzed, 8 superficial lesions and 37 deep lesions. On ultrasound, the superficial GA corresponded to hypoechoic poorly defined solid plaque like or nodular lesions, located in the dermal-epidermal plane. The deep GA presented as solid nodular, poorly defined hypoechoic lesions that compromised the deep subcutaneous-aponeurotic plane. CONCLUSION: GA is an inflammatory lesion that presents as a superficial or deep palpable nodule that predominantly affects children. Superficial and deep GA present characteristic findings on US that can guide the diagnosis. The radiologist needs to know its US appearance to be able to suggest the diagnosis, especially in multiples lesions.

CD34 Staining as a Useful Tool in Disorders of Collagen Degeneration.

ABSTRACT: The human progenitor-cell antigen CD34 is expressed in dermal dendritic cells and is lost in several disorders affecting dermal collagen. The loss of CD34 immunohistochemical staining has been demonstrated to be helpful in the histologic diagnosis of morphea, lichen sclerosus, and the classic pattern of granuloma annulare. This study characterized CD34 expression in 2 sclerosing disorders affecting the subcutis: lipodermatosclerosis (LDS) and the sclerodermoid form of chronic graft-versus-host disease (ScGVHD). In addition, we applied CD34 staining to the interstitial pattern of granuloma annulare (IGA), which is a diagnostically challenging entity with subtle amounts of dermal collagen degeneration. Fifteen cases of LDS, 6 cases of ScGVHD, and 4 cases of IGA were identified and stained with CD34. All cases of LDS showed loss of CD34 within subcutaneous septa, and 9 cases (60%) also exhibited full-thickness dermal loss of interstitial staining. All 6 cases of ScGVHD showed varying degrees of CD34 loss within the dermis and/or subcutaneous septa. The normal subcutis showed diffuse septal staining with CD34, with a density equal to that seen in the dermis. CD34 staining was lost in areas of dermal inflammation in half of the IGA cases. We conclude that CD34 staining is a useful ancillary test in disease processes affecting the subcutaneous collagen such as LDS and ScGVHD. Its utility also extends to diagnostically challenging disorders of dermal collagen degeneration such as IGA.

Granuloma annulare subtypes: sonographic features and clinicopathological correlation.

PURPOSE: Diagnosis of granuloma annulare (GA) is based on the clinical and histopathological findings. However, only sporadic case reports of subcutaneous GA sonography have been published to date. The objective of this study was to evaluate the ultrasonographic patterns of the different clinical variants of GA: localized, generalized, subcutaneous, and perforating. METHODS: In this retrospective observational study, we analyzed and correlated the clinical, histopathological, and sonographic features of 15 patients diagnosed with GA. RESULTS: We included 8 women and 7 men with a mean age of 48.4 years (8-77 years). We found three different sonographic patterns depending on the clinical variant of GA: poorly defined hypoechoic band including the dermis (dermal pattern), irregularly shaped hypoechoic hypodermal lumps (hypodermal pattern), and ill-defined hypoechoic dermal and subcutaneous lesions (mixed pattern). Five cases showed increased blood flow signal on Doppler interrogation. CONCLUSION: Although our findings are broadly consistent with the previous reports of subcutaneous GA, the sonographic features in localized, generalized, and perforating GA have not been previously reported.

Dermatoscopy of Granulomatous Disorders.

Although diagnosis of cutaneous granulomatous disorders (CGDs) is usually suspected based on morphologic findings, localization, and anamnestic data, clinical differentiation from each other and from similar dermatoses may be challenging. Recently, dermatoscopy has been demonstrated to be a useful tool for assisting the recognition of several CGDs. This article provides a current overview of the dermatoscopic features of the main noninfectious and infectious CGDs, including sarcoidosis, necrobiosis lipoidica, granuloma annulare, rheumatoid nodules, and leishmaniasis. Other, less common, CGDs are briefly addressed, including granulomatous rosacea, acne agminata, and leprosy.

Paraneoplastic granulomatous dermatitis in a patient with Hodgkin's disease: a diagnostic pitfall.

The association of malignant lymphomas with non-necrotic epithelioid granulomas has been reported rarely since 1977. Hodgkin's disease-associated widespread cutaneous granuloma annulare (GA) has been reported in only eight patients. We report the second case of subcutaneous GA associated with Hodgkin's disease. A 73-year-old man with Epstein-Barr virus-associated Hodgkin's lymphoma and paraneoplastic subcutaneous GA, presented 3 months after the diagnosis of malignancy. Examination revealed a large, broad erythematous, indurated, subcutaneous plaque spanning the majority of the left lower back and flank with no associated symptoms. Initial biopsy was suggestive of morphea. Prompted by positron emission tomography (PET) findings of increased fluorodeoxyglucose (FDG) uptake, a second, deeper biopsy was performed, revealing subcutaneous palisaded granulomatous dermatitis. After complete workup, the diagnosis most strongly suggested subcutaneous GA. This case highlights the importance of deep incisional biopsies, the fluorodeoxyglucose - positron emission tomography (FDG-PET) findings in GA and the rare association of GA with Hodgkin's disease which may signal the presence of malignancy.

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.

Dermoscopy of Granuloma Annulare: A Clinical and Histological Correlation Study.

BACKGROUND: Dermoscopy of granuloma annulare has been investigated by several studies, but none of them took into account the variability of dermoscopic findings according to clinical characteristics and/or histological subtype. OBJECTIVE: To describe the dermoscopic features of classic granuloma annulare and seek possible dermoscopic clues related to specific clinical findings/histological subpatterns. METHODS: A representative dermoscopic image of a target lesion (the most active lesion underwent histological examination) was retrospectively assessed for the presence of specific morphological findings, correlating them with clinical variables, i.e. disease duration and extension (localized or generalized) and clinical aspect (annular or non-annular) and localization (trunk or extremities) of the biopsied lesion, and with histological subtype. RESULTS: A total of 25 lesions from 25 subjects were analysed; an "interstitial" histological variant was detected in 11 cases, while a "palisading granuloma" histological pattern was found in 14 instances. The most common dermoscopic findings included blurry vessels having variable appearance (dotted, linear-irregular, and branching) over a more or less evident pinkish-reddish background, followed by whitish and/or yellowish-orange areas. Additional findings were rosettes, crystalline structures, and whitish scaling. No difference (p > 0.05) in the frequency of dermoscopic features according to clinical findings was found, while we observed a strict association (p < 0.001) between the presence of yellowish-orange structureless areas on dermoscopy and "palisading granuloma" histology. CONCLUSION: The dermoscopic aspect of granuloma annulare is independent from clinical features but varies according to histological subtype, with the detection of yellowish-orange colour being indicative of the "palisading granuloma" variant.

Subcutaneous Granuloma Annulare: A Diagnostic Conundrum-Learning From Mistakes.

Subcutaneous granuloma annulare is an inflammatory lesion occurring in otherwise healthy children. We present 3 pediatric patients with different diagnostic-therapeutic paths depending on the ward they were referred to. The lesions regress spontaneously, and medical or surgical treatments are generally not necessary.

Soft tissue masses in children.

The diagnosis of soft tissue masses in children can be challenging because there is a broad spectrum of entities that can present as such. Ultrasonography is the primary diagnostic imaging modality in the pediatric age and is especially useful for small and superficial lesions. MR imaging can be helpful, particularly in the evaluation of large and deep soft tissue lesions. Correlation of the imaging findings with the clinical information is crucial in the diagnostic work-up. This article reviews the most common causes of soft tissue masses that require imaging in children.

[Subcutaneous annular granuloma: a differential diagnosis not to be forgotten in expansive lower leg (soft-tissue) lesions of young children]. / Subkutanes Granuloma annulare: eine nicht zu vergessende Differenzialdiagnose bei expansiven (Weichteil-) Läsionen an den unteren Extremitäten von jungen Kindern.

PURPOSE: Expansive lower leg lesions in children include numerous, even malignant, entities. Good differential diagnostic knowledge is extremely important in those conditions in order to prevent unnecessary biopsy. Therefore, our own observations of a not particularly rare pseudotumorous soft-tissue disease are presented and the value of ultrasonography is emphasized. MATERIALS AND METHODS: The imaging material (sonograms in all, MRI and radiograms in the first 4 and 3 patients, respectively) and the clinical charts of 7 young children (4 females, 3 males; aged 28 - 65 months) were analyzed retrospectively. RESULTS: All lesions were pretibial, firm, indolent, non-movable, and without inflammatory signs. They had developed spontaneously. Laboratory tests were normal. Ultrasound demonstrated all lesions located subcutaneously, homogeneously echopoor with indistinct borders and only little increased perfusion. On MRI they presented with low signal in T 1, high in T 2 and marked contrast enhancement. No intraosseous changes or calcifications were found. Histological proof in the first 2 patients disclosed subcutaneous annular granuloma. Based on an identical clinical and sonographic initial presentation, biopsy and additional imaging were dispensed in the later patients. Their clinical course with only sonographic controls was as expected. CONCLUSION: When dealing with expansive lower leg soft-tissue lesions in young children, the presented typical clinical and sonographic findings should give rise to consideration of the benign entity of subcutaneous annular granuloma and primary monitoring of those patients with only ultrasound.

Pretibial subcutaneous soft tissue lesions presenting to a paediatric orthopaedic clinic.

Pretibial swellings in children usually represent erythema nodosum which exhibits characteristic skin changes. Three cases of pretibial subcutaneous lesions are presented which had no skin involvement or bony abnormalities on plain radiographs. At initial presentation, concerns of malignancy were raised but these lesions were ultimately diagnosed as granuloma annulare, fat necrosis and subcutaneous infection. In combination with clinical assessment and plain radiographs, MRI proved invaluable in reaching diagnosis and excluding neoplasia. Biopsy was only required in one case in this series after MRI. A tissue diagnosis, however, remains mandatory if there is any doubt over the nature of such lesions.

Widespread granuloma annulare and Hodgkin's disease.

The presence of coexistent disseminated granuloma annulare (GA) and Hodgkin's disease (HD) is rare, with only six reported patients to date. We describe a patient with HD who had limited GA 2 years before the diagnosis of HD; widespread GA appeared after first-line treatment and heralded disease relapse. GA lesions showed hypermetabolic images on positron emission tomography, an interesting finding of unknown significance. We suggest a new pathophysiological mechanism for this association, i.e. that the reactive T-lymphocyte population in HD may contribute to granuloma formation through the secretion of cytokines and the subsequent upregulation of certain metalloproteinases. Diffuse cutaneous GA should raise the possibility of underlying systemic lymphoma or HD.

Subcutaneous granuloma annulare of the scalp in childhood: a case report and review of the literature.

Granuloma annulare is a benign inflammatory skin lesion of unknown etiology that is usually seen in adults and children and subtypes of it includes localized granuloma annulare, generalized granuloma annulare, subcutaneous granuloma annulare and arcuate dermal erythema. Etiology and pathogenesis of granuloma annulare are obscure, although there is much evidence for an immunologic mechanism. Precipitating factors are insect bites, sunburn, photochemotherapy, drugs, physical trauma, acute phlebitis and sepsis after surgery. Some investigators were suggested a relationship of granuloma annulare to a latent or clinically manifest diabetes or rheumatoid arthritis. In contrast, an association of subcutaneous granuloma annulare with these diseases in childhood has not been reported in the literature. Subcutaneous granuloma annulare of the scalp is rare lesion in childhood and nodules on the scalp are usually non-, or slightly mobile, whereas lesions on the extremities are freely mobile. For definitive diagnosis, a biopsy should be performed but wide surgical intervention or medical treatment is not indicated. In case of recurrence, no additional diagnostic studies are necessary.

Subcutaneous granuloma annulare: radiologic appearance.

OBJECTIVE: Granuloma annulare is an uncommon benign inflammatory dermatosis characterized by the formation of dermal papules with a tendency to form rings. There are several clinically distinct forms. The subcutaneous form is the most frequently encountered by radiologists, with the lesion presenting as a superficial mass. There are only a few scattered reports of the imaging appearance of this entity in the literature. We report the radiologic appearance of five cases of subcutaneous granuloma annulare. DESIGN AND PATIENTS: The radiologic images of five patients (three male, two female) with subcutaneous granuloma annulare were retrospectively studied. Mean patient age was 6.4 years (range, 2-13 years). The lesions occurred in the lower leg (two), foot, forearm, and hand. MR images were available for all lesions, gadolinium-enhanced imaging in three cases, radiographs in four, and bone scintigraphy in one. RESULTS: Radiographs showed unmineralized nodular masses localized to the subcutaneous adipose tissue. The size range, in greatest dimension on imaging studies, was 1-4 cm. MR images show a mass with relatively decreased signal intensity on all pulse sequences, with variable but generally relatively well defined margins. There was extensive diffuse enhancement following gadolinium administration. CONCLUSION: The radiologic appearance of subcutaneous granuloma annulare is characteristic, typically demonstrating a nodular soft-tissue mass involving the subcutaneous adipose tissue. MR images show a mass with relatively decreased signal intensity on all pulse sequences and variable but generally well defined margins. There is extensive diffuse enhancement following gadolinium administration. Radiographs show a soft-tissue mass or soft-tissue swelling without evidence of bone involvement or mineralization. This radiologic appearance in a young individual is highly suggestive of subcutaneous granuloma annulare.