Case for Diagnosis
Asymptomatic Nodule on the Leg
Nódulo asintomático en la pierna
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González Fernández, B. Vivanco Allende, S. Gómez Díez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "González Fernández" "email" => array:1 [ 0 => "danigf81@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "B." "apellidos" => "Vivanco Allende" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Gómez Díez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nódulo asintomático en la pierna" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 751 "Ancho" => 1089 "Tamanyo" => 94314 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Description</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">An 82-year-old woman with a history of hypertension and atrial fibrillation presented with an asymptomatic raised erythematous lesion on her right leg. The lesion had been first observed more than 6 months earlier. The patient reported that the lesion had grown gradually and did not link it to any other event.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed a single, oval-shaped nodular lesion 2.5<span class="elsevierStyleHsp" style=""></span>cm in diameter on the right leg. The central area of the lesion was erythematous, indurated, and raised, while the periphery was flat and whitened with a somewhat indistinct border. The central area was perforated and visibly exuded keratotic material (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The lesion was not tender and body temperature was not elevated.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">The lesion was completely excised. Histopathologic examination showed epidermal acanthosis and hyperkeratosis. The superficial and mid dermis contained several granulomas with central areas of necrobiosis surrounded by epithelioid histiocytes, lymphocytes, and multinucleated giant cells. Some of these granulomatous lesions were close to the epidermis and had broken through it, releasing necrobiotic material. Colloidal iron staining revealed mucin deposits (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis?</span></p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis and Discussion</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Localized perforating granuloma annulare.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical Course and Treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">After excision, direct closure was performed by layers. There were no wound complications and the patient has developed no further lesions.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Perforating granuloma annulare (PGA) was first described by Owens and Freeman<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> in 1971, but had been previously described as a tuberculoulcerous form of granuloma annulare by Pinkus in 1934 and Civatte<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> in 1952.</p><p id="par0040" class="elsevierStylePara elsevierViewall">PGA is a rare form of granuloma annulare, accounting for only 5% of all cases. Most patients are children and young adults; mean age at diagnosis is 30 years, and there is a 1:1.8 male to female ratio.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The etiology of PGA is still poorly understood. PGA is classified according to the number and location of the lesions. It is termed <span class="elsevierStyleItalic">generalized PGA</span> when it involves the trunk and limbs, <span class="elsevierStyleItalic">disseminated PGA</span> when it only involves the limbs, and <span class="elsevierStyleItalic">localized PGA</span> when there are very few lesions in a single area.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Localized PGA primarily occurs on the upper limbs and palms.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> About 9% of cases consist of single lesions.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">PGA may sometimes present as reddish papules measuring 1 to 5<span class="elsevierStyleHsp" style=""></span>mm, with umbilication or central crusting.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> In 17% of cases, PGA is associated with diabetes mellitus; the age of onset is higher in this subgroup.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Other reported associations include human immunodeficiency virus, herpes zoster, tuberculosis, hypothyroidism, lymphomas, rheumatoid arthritis, coronary syndromes, bronchitis, and rhinitis.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Microscopically, PGA is characterized by the presence in the superficial or mid dermis of one or more necrobiotic granulomas containing central areas of mucin, degenerated collagen, and fibrin surrounded by histiocytes, lymphocytes, and multinucleated giant cells. A channel, ulcer, or area of destroyed epidermis can be observed through which necrobiotic material is eliminated. This material is typically covered by a crust or by parakeratotic stratum corneum. Increased presence of mucin is found in 70% of lesions.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Differential diagnosis includes molluscum contagiosum, primary perforating disorders, bites and stings, keratoacanthoma, pityriasis lichenoides et varioliformis acuta, papulonecrotic tuberculid, and perforating forms of sarcoidosis or necrobiosis lipoidica.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Localized lesions and asymptomatic lesions regress spontaneously in 70% of cases and thus require no treatment. Topical treatments used for PGA include corticosteroids, calcineurin inhibitors, and vitamin E, while systemic treatment may be attempted using dapsone, retinoids, antimalarial agents, pentoxifylline, nicotinamide, tumor necrosis factor inhibitors, or phototherapy. No absolute benefit has been shown for any of these treatments, and there is no clinical trial evidence to support their use.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Case Description" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Histopathology" ] ] ] 1 => array:3 [ "identificador" => "sec0025" "titulo" => "Diagnosis and Discussion" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Diagnosis" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Clinical Course and Treatment" ] ] ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González Fernández D, Vivanco Allende B, Gómez Díez S. Nódulo asintomático en la pierna. Actas Dermosifiliogr. 2015;106:229–230.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 751 "Ancho" => 1089 "Tamanyo" => 94314 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1085 "Ancho" => 1296 "Tamanyo" => 433593 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×2.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1131 "Ancho" => 1502 "Tamanyo" => 718217 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×20.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perforating granuloma annulare" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.W. Owens" 1 => "R.G. Freeman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "1971" "volumen" => "103" "paginaInicial" => "64" "paginaFinal" => "67" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5539506" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Les formes tuberculo-ulcereuses et tuberculo-gommeuses du granuloma annulaire" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A. 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García-Díez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1046/j.1365-4362.1997.00047.x" "Revista" => array:7 [ "tituloSerie" => "Int J Dermatol" "fecha" => "1997" "volumen" => "36" "paginaInicial" => "340" "paginaFinal" => "348" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9199980" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0093775414001730" "estado" => "S300" "issn" => "00937754" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Generalized granuloma annulare: Clinical and laboratory findings in 100 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K. Dabsky" 1 => "R.K. Winkelmann" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0190-9622(89)70005-0" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "1989" "volumen" => "20" "paginaInicial" => "39" "paginaFinal" => "47" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2913080" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pustular generalized perforating granuloma annulare" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. Gamo Villegas" 1 => "J. Sopena Barona" 2 => "A. Guerra Tapia" 3 => "A. Vergara Sánchez" 4 => "J.L. Rodríguez Peralto" 5 => "L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 14 | 28 |
| 2024 October | 108 | 44 | 152 |
| 2024 September | 81 | 26 | 107 |
| 2024 August | 118 | 50 | 168 |
| 2024 July | 71 | 37 | 108 |
| 2024 June | 68 | 29 | 97 |
| 2024 May | 64 | 26 | 90 |
| 2024 April | 53 | 26 | 79 |
| 2024 March | 66 | 33 | 99 |
| 2024 February | 48 | 32 | 80 |
| 2024 January | 51 | 36 | 87 |
| 2023 December | 38 | 14 | 52 |
| 2023 November | 40 | 27 | 67 |
| 2023 October | 43 | 21 | 64 |
| 2023 September | 66 | 27 | 93 |
| 2023 August | 43 | 19 | 62 |
| 2023 July | 44 | 36 | 80 |
| 2023 June | 51 | 17 | 68 |
| 2023 May | 61 | 24 | 85 |
| 2023 April | 50 | 20 | 70 |
| 2023 March | 46 | 29 | 75 |
| 2023 February | 49 | 21 | 70 |
| 2023 January | 38 | 24 | 62 |
| 2022 December | 37 | 29 | 66 |
| 2022 November | 17 | 24 | 41 |
| 2022 October | 25 | 20 | 45 |
| 2022 September | 24 | 30 | 54 |
| 2022 August | 25 | 29 | 54 |
| 2022 July | 20 | 27 | 47 |
| 2022 June | 24 | 20 | 44 |
| 2022 May | 55 | 30 | 85 |
| 2022 April | 68 | 41 | 109 |
| 2022 March | 67 | 37 | 104 |
| 2022 February | 43 | 26 | 69 |
| 2022 January | 53 | 27 | 80 |
| 2021 December | 37 | 31 | 68 |
| 2021 November | 43 | 39 | 82 |
| 2021 October | 46 | 39 | 85 |
| 2021 September | 34 | 36 | 70 |
| 2021 August | 30 | 20 | 50 |
| 2021 July | 27 | 30 | 57 |
| 2021 June | 46 | 26 | 72 |
| 2021 May | 27 | 19 | 46 |
| 2021 April | 74 | 40 | 114 |
| 2021 March | 44 | 10 | 54 |
| 2021 February | 44 | 22 | 66 |
| 2021 January | 28 | 10 | 38 |
| 2020 December | 24 | 10 | 34 |
| 2020 November | 23 | 11 | 34 |
| 2020 October | 17 | 18 | 35 |
| 2020 September | 22 | 8 | 30 |
| 2020 August | 32 | 16 | 48 |
| 2020 July | 24 | 8 | 32 |
| 2020 June | 45 | 18 | 63 |
| 2020 May | 24 | 15 | 39 |
| 2020 April | 32 | 14 | 46 |
| 2020 March | 25 | 14 | 39 |
| 2020 February | 6 | 0 | 6 |
| 2020 January | 6 | 4 | 10 |
| 2019 December | 8 | 5 | 13 |
| 2019 November | 4 | 1 | 5 |
| 2019 September | 4 | 4 | 8 |
| 2019 August | 4 | 1 | 5 |
| 2019 July | 4 | 1 | 5 |
| 2019 June | 4 | 1 | 5 |
| 2019 May | 6 | 14 | 20 |
| 2019 April | 2 | 0 | 2 |
| 2019 March | 4 | 6 | 10 |
| 2019 February | 5 | 0 | 5 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 4 | 0 | 4 |
| 2018 July | 0 | 1 | 1 |
| 2018 June | 0 | 1 | 1 |
| 2018 May | 0 | 2 | 2 |
| 2018 February | 22 | 1 | 23 |
| 2018 January | 33 | 5 | 38 |
| 2017 December | 37 | 4 | 41 |
| 2017 November | 17 | 6 | 23 |
| 2017 October | 22 | 7 | 29 |
| 2017 September | 14 | 4 | 18 |
| 2017 August | 19 | 7 | 26 |
| 2017 July | 13 | 4 | 17 |
| 2017 June | 26 | 16 | 42 |
| 2017 May | 19 | 3 | 22 |
| 2017 April | 26 | 4 | 30 |
| 2017 March | 13 | 43 | 56 |
| 2017 February | 15 | 4 | 19 |
| 2017 January | 12 | 6 | 18 |
| 2016 December | 29 | 6 | 35 |
| 2016 November | 39 | 13 | 52 |
| 2016 October | 29 | 6 | 35 |
| 2016 September | 0 | 8 | 8 |
| 2016 July | 8 | 1 | 9 |
| 2016 June | 9 | 5 | 14 |
| 2016 May | 6 | 19 | 25 |
| 2016 April | 6 | 13 | 19 |
| 2016 March | 2 | 18 | 20 |
| 2016 February | 0 | 13 | 13 |
| 2016 January | 13 | 13 | 26 |
| 2015 December | 3 | 5 | 8 |
| 2015 November | 5 | 1 | 6 |
| 2015 October | 1 | 0 | 1 |
| 2015 September | 0 | 4 | 4 |
| 2015 August | 0 | 1 | 1 |
| 2015 July | 3 | 3 | 6 |
| 2015 June | 1 | 1 | 2 |
| 2015 May | 2 | 5 | 7 |
| 2015 April | 1 | 16 | 17 |
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