Granuloma annulare after SARS-CoV-2 vaccination: A case report and a literature review.

INTRODUCTION: During the Cov-19 pandemic, many studies reported a broad spectrum of cutaneous reactions presenting as erythematous rashes or pernio-like, urticaria-like or vesicular/bullous patterns associated with Cov-19-infection and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. METHODS: The authors documented the clinical and histopathological features of an unexpected case of granuloma annulare (GA) arising a few days after the SARS-CoV-2 vaccination and reviewed all GAs reported in the literature following the SARS-CoV-2 vaccination and Cov-19-infection. CASE REPORT: A 69-year-old woman developed a single reddish lesion on the left deltoid region, where the SARS-CoV-2 vaccine seven days earlier was injected. The clinicians performed a punch skin biopsy, and histology revealed an interstitial GA. CONCLUSIONS: Clinicians should be aware of the potential, though rare, GA occurrence as a possible adverse event after the SARS-CoV-2 vaccination. This additional case, like what happens after the administration of other vaccines, supports the idea that GA may result from the immune system activation following the vaccination. However, notwithstanding, they should encourage their patients to obtain immunization to assist the public health systems in overcoming the COVID-19 pandemic.

Light- and laser-based treatments for granuloma annulare: A systematic review.

BACKGROUND: Granuloma annulare (GA) is challenging to treat, especially when generalized. A systematic review to support the use of light- and laser-based treatments for GA is lacking. METHODS: We performed a systematic review by searching Cochrane, MEDLINE, and Embase. Title, abstract, full-text screening, and data extraction were done in duplicate. Quality appraisal was performed using the Joanna Briggs Institute critical appraisal tool for case series. RESULTS: Thirty-one case series met the inclusion criteria, representing a total of 336 patients. Overall, psoralen ultraviolet light A (PUVA) showed the greatest frequency of cases with complete response (59%, n = 77/131), followed by photodynamic therapy (PDT) (52%, n = 13/25), ultraviolet light B (UVB)/narrowband UVB (nbUVB)/excimer laser (40%, n = 19/47), UVA1 (31%, n = 27/86), and lasers (29%, n = 8/28). Overall across treatment modalities, higher response rates were seen in localized GA compared to generalized GA. CONCLUSIONS: The body of evidence for light- and laser-based treatment of GA is sparse. Our results suggest that PUVA has a high clearance rate for GA but its use may be limited by concerns of carcinogenesis. Although PDT has the second highest clearance rate, adverse effects, small sample sizes, impractical treatment delivery (especially with generalized disease), and long-term concerns of carcinogenesis may limit its use. Although UVB/nbUVB/excimer laser appeared slightly less effective than other light therapies, we recommend UVB/nbUVB/excimer laser therapy as a first-line treatment for patients with generalized GA given wider availability and a favorable long-term safety profile.

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.

Paraneoplastic Granuloma Annulare Associated with Metastatic Lung Cancer.

A 60-year-old Caucasian woman with a 15-year smoking history presented with new, asymptomatic, pink lesions that gradually appeared over a period of 6 weeks. Physical examination revealed erythematous annular and nummular plaques on her upper and lower extremities, chest, and abdomen (Figure 1A and 1B). A shave biopsy from the right thigh revealed focal areas of necrobiotic collagen in the superficial portion of the dermis, surrounded by histiocytes, multinucleated giant cells, and lymphocytes, consistent with granuloma annulare (GA) (Figure 2).1.

Association of Granuloma Annulare With Type 2 Diabetes, Hyperlipidemia, Autoimmune Disorders, and Hematologic Malignant Neoplasms.

IMPORTANCE: Although granuloma annulare (GA) has been associated with several other conditions, these studies have been limited by single-center designs and small sample sizes. OBJECTIVE: To evaluate whether there is an association between GA and type 2 diabetes, hyperlipidemia, autoimmune conditions, and hematologic malignant neoplasms, using a large population-based cohort study. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study conducted between January 1, 2016, and June 30, 2019, used deidentified data from the US Optum Clinformatics Data Mart Database. A total of 5137 patients with GA were matched by age and sex with up to 10 randomly selected controls (n = 51 169) with a diagnosis of a nevus or seborrheic keratosis. MAIN OUTCOMES AND MEASURES: Logistic regression was used to evaluate for potential associations between GA and diabetes, hyperlipidemia, autoimmune conditions, and hematologic malignant neoplasms. All analyses were adjusted for race/ethnicity, income, and educational level. RESULTS: This study included 5137 individuals with GA (3760 women [73.2%]; mean [SD] age, 57.7 [19.0] years) and 51 169 controls (37 456 women [73.2%]; mean [SD] age, 57.7 [19.0] years). Those with GA were more likely than controls to have baseline diabetes (1086 [21.1%] vs 6780 [13.3%]; adjusted odds ratio [aOR], 1.67; 95% CI, 1.55-1.80), hyperlipidemia (1669 [32.5%] vs 14 553 [28.4%]; aOR, 1.15; 95% CI, 1.08-1.23), hypothyroidism (727 [14.2%] vs 5780 [11.3%]; aOR, 1.24; 95% CI, 1.15-1.36), and rheumatoid arthritis (62 [1.2%] vs 441 [0.9%]; aOR, 1.34; 95% CI, 1.02-1.75). Those with GA were more likely to have incident diabetes (144 [2.8%] vs 1061 [2.1%]; aOR, 1.31; 95% CI, 1.10-1.57), hypothyroidism (41 [0.8%] vs 252 [0.5%]; aOR, 1.59; 95% CI, 1.14-2.22), systemic lupus erythematosus (21 [0.4%] vs 65 [0.1%]; aOR, 3.06; 95% CI, 1.86-5.01), and rheumatoid arthritis (26 [0.5%] vs 122 [0.2%]; aOR, 2.05; 95% CI, 1.34-3.13). There was no association between GA and an increased risk of hematologic malignant neoplasms. CONCLUSIONS AND RELEVANCE: This population-based cohort study identified associations between GA and baseline diabetes and hyperlipidemia as well as between GA and both baseline and incident autoimmune conditions. These findings suggest that diabetes and hyperlipidemia may be risk factors for the development of GA and that autoimmunity may be an important factor in the pathogenesis of GA.

Interstitial granuloma annulare triggered by Lyme disease.

Granuloma annulare is a non-infectious granulomatous skin condition with multiple different associations. We present a case of a man in his 60s with a three-week history of progressive targetoid plaques on his arms, legs, and trunk. Skin biopsy demonstrated interstitial granuloma annulare. Additional testing revealed IgM antibodies to Borrelia burgdorferi on western blot suggesting interstitial granuloma annulare was precipitated by the recent infection. Lyme disease is an uncommonly reported association with interstitial granuloma annulare.

[Granuloma annulare after herpes zoster: Wolf's isotopic response]. / Granuloma annulare na herpes zoster.

BACKGROUND: The term Wolf's isotopic response has been used to describe the occurrence of a new skin disorder at the site of another, unrelated and already healed skin disease. CASE DESCRIPTION: A 74-year-old man with type 2 diabetes mellitus and prostate carcinoma with osseous and lymphatic metastases developed a herpes zoster infection of the left shoulder after palliative radiation therapy of this area. After several months multiple lenticular erythematous papules and some plaques were seen at the previously infected location. The diagnosis granuloma annulare was confirmed by a punch biopsy. CONCLUSION: This case report will increase clinical awareness and will thereby prevent the prescription of unnecessary repeated antiviral medication.

Generalized granuloma annulare after pneumococcal vaccination

Abstract Granuloma annulare may be caused by multiple triggers. Among these are vaccinations, which have been described as an infrequent cause of granuloma annulare. The authors report the first case of generalized granuloma annulare associated with pneumococcal vaccination in a 57-year-old woman, who presented cutaneous lesions 12 days after vaccination.

Granuloma anular fotoinducido demostrado experimentalmente mediante fotoprovocación UVA / Photoinduced Granuloma Annulare Confirmed by Experimental Exposure to UVA Light

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Granulomatous Cutaneous Drug Eruptions: A Systematic Review.

BACKGROUND: Granulomatous drug eruptions are rare entities, where granuloma formation occurs as an attempt to contain an exogenous or endogenous inciting agent. Granulomatous drug eruptions may be localized to the skin or may include major systemic involvement, and their characteristics depend both on the properties of the causative irritant and host factors. Because of the overlapping features amongst noninfectious granulomatous diseases, granulomatous drug eruptions are challenging to diagnose and distinguish both histologically and clinically. OBJECTIVE: The objective of this article is to provide a review and summary of the current literature on the five major types of cutaneous granulomatous drug eruptions: interstitial granulomatous drug reaction, drug-induced accelerated rheumatoid nodulosis, drug-induced granuloma annulare, drug-induced sarcoidosis, and miscellaneous presentations. METHODS: A systematic review was conducted through PubMed using the search terms "granulomatous drug eruption" and "cutaneous" or "skin". English full-text studies that included human subjects experiencing a cutaneous reaction comprising granulomatous inflammation as the direct result of a drug were included. Of 205 studies identified, 48 articles were selected after a full-text review. Evidence was evaluated using the Tool for evaluating the methodological quality of case reports and case series. RESULTS: Polypharmacy and a prolonged lag period from drug ingestion to rash onset may create diagnostic challenges. Ruling out tuberculosis is imperative in the endemic setting, particularly where anti-tumor necrosis factor therapy is the presumed cause. Interstitial granulomatous drug reactions and granuloma annulare are often localized to the skin whereas accelerated rheumatoid nodulosis and sarcoidosis may sometimes be associated with systemic features as well. Granulomatous drug eruptions typically resolve on discontinuing the offending medication; however, the decision for drug cessation is dependent on a risk-benefit assessment. In some situations, supplementation of an additional agent to suppress the reaction may resolve symptoms. In some cases, granulomatous drug eruptions may be pivotal in the successful outcome of the drug, as in cases of melanoma treatment. In all situations, the decision to continue or withdraw the drug should be carefully based on the severity of the eruption, necessity of continuing the drug, and availability of a suitable alternative. CONCLUSIONS: Granulomatous drug eruptions should always be considered in the differential diagnosis of noninfectious granulomatous diseases of the skin. Further research examining dose-response relationships and the recurrence of granulomatous drug eruptions on the rechallenge of offending agents is required. Increased awareness of granulomatous drug eruption types is important, especially with continuous development of new anti-cancer agents that may induce these reactions. CLINICAL TRIAL REGISTRATION: PROSPERO registration number CRD42020157009.

Generalized granuloma annulare after pneumococcal vaccination.

Granuloma annulare may be caused by multiple triggers. Among these are vaccinations, which have been described as an infrequent cause of granuloma annulare. The authors report the first case of generalized granuloma annulare associated with pneumococcal vaccination in a 57-year-old woman, who presented cutaneous lesions 12 days after vaccination.

Granuloma annulare-like eruption in chronic lymphocytic leukemia.

We report a patient with new-onset ulcerated granuloma annulare with concomitant involvement of B-cell leukemia. A granuloma annulare-like eruption with concomitant B cell chronic lymphocytic leukemia involvement in the skin is extremely rare, as only three cases have been previously reported in the literature to our knowledge. Given the rarity of ulceration in conventional granuloma annulare, it is possible this finding may serve as a diagnostic clue for underlying malignancy.

Unusual Case of Granuloma Annulare Associated with Diabetes Mellitus.

Dear Editor, Granuloma annulare (GA) is an asymptomatic, chronic, and relatively common granulomatous skin condition which presents with annular papules usually slowly progressing into plaques on the extremities and the trunk. It usually presents with non-scaly, erythematous, annular plaques on the distal extremity (1,2). The pathogenesis of GA is still unknown, although a variety of possible factors contributing the disease have been reported, including drugs (3), insect bites, sun exposure, trauma, vaccinations, and viral infections (e.g. hepatitis B, hepatitis C, HIV, Epstein-Barr virus) (1). Several cases in which GA developed on residual skin changes from herpes zoster have also been reported (4). A 47-year-old woman presented with erythematous-livid plaques on the dorsa of her hands and linear and circular lesions on her neck, gradually spreading for the last 4 months prior to admission at our Department (Figure 1a and Figure 1b). She reported excessive thirst and sweating in the last 30 days, but did not consider it significant since it was summer. The patient was otherwise healthy and was not taking any medications. Mycological swabs taken from the dorsal parts of both hands and the neck were negative. Biopsy of the skin changes was consistent with GA, showing palisading granulomatous inflammation which surrounded degenerated collagen within the dermis. A routine laboratory check revealed increased levels of glucose (23 mmol/L) and HgbA1C, while lipid and thyroid hormone levels were normal. Fasting blood sugar lever was 17 mmol/L. Therapy with topical corticosteroid (betamethasone cream) for skin lesions was initiated and applied two times daily for 2 weeks. The patient was immediately referred to an endocrinologist and insulin therapy was initiated due to diabetes mellitus. Complete remission of the skin changes was observed on the follow-up visit after 3 months. There are many clinical variants of GA such as localized, generalized, disseminated, subcutaneous, arcuate dermal erythema, and perforating GA (1). The localized form of GA is most common with annular plaques on the distal extremities. In addition to the typical lesions on the dorsal side of both hands, our patient also presented with atypical, circular lesions around her neck. The relationship between GA and systemic diseases such as diabetes mellitus, thyroid disorders, dyslipidemia, and malignancies remains unclear (5). It is also uncertain whether genetic factors influence susceptibility to GA. Familial cases have been documented, but studies investigating the association between the disease and human leukocyte antigen (HLA) genes have yielded inconsistent results (6). Increased frequency of HLA-B35 in patients with the generalized form has been reported in a few studies (7). GA mostly affects children and young adults, mostly women. Many cases of GA resolve spontaneously within 2 years, but relapses occur in many patients. Treatment is divided into localized skin therapies and systemic therapies (1). High potency topical corticosteroids along with intralesional corticosteroids are the most common localized treatments (8). Systemic therapy includes corticosteroids, chloroquine, dapsone, and isotretinoin (1,9). Cryotherapy and UV-therapy can also be used, although with limited efficacy (10). GA is a common idiopathic disorder of the dermis and subcutaneous tissue that can be associated with a variety of underlying conditions such as diabetes mellitus. The relationship between GA and diabetes mellitus is still unknown. Since skin lesions preceded the diagnosis of DM in our patient and complete remission of skin changes occurred with induction of insulin therapy, it is important to perform routine laboratory test in every patient.

Cutaneous Manifestations of Diabetes Mellitus and Prediabetes.

Diabetes is a serious, chronic disease with a rising prevalence worldwide. Its complications are a major cause of morbidity and mortality and contribute substantially to health care costs. In this article the authors review the most common and sensitive skin manifestations that can be present on patients with diabetes and prediabetes. The prompt recognition of these frequently underestimated entities is extremely important as it may trigger not only an adequate metabolic evaluation but also a timely referral and appropriate treatment, minimizing the secondary effects of long-term diabetes and improving the prognosis of diabetic patients.

A diabetes mellitus é uma doença crónica, com uma prevalência crescente a nível mundial. As complicações da diabetes são uma causa major de morbilidade e mortalidade, condicionando custos importantes na área da saúde. Neste artigo é efetuada uma revisão das manifestações cutâneas mais frequentes presentes em doentes com diabetes e pré-diabetes. O reconhecimento atempado destas entidades é fulcral, levando não só a uma avaliação atempada do perfil metabólico como a uma referenciação e tratamento precoces. Desta forma, é possível minimizar os efeitos secundários da diabetes a longo prazo, melhorando significativamente o prognóstico dos doentes.