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." 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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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 12 | 13 | 25 |
| 2024 Octubre | 108 | 44 | 152 |
| 2024 Septiembre | 81 | 26 | 107 |
| 2024 Agosto | 118 | 50 | 168 |
| 2024 Julio | 71 | 37 | 108 |
| 2024 Junio | 68 | 29 | 97 |
| 2024 Mayo | 64 | 26 | 90 |
| 2024 Abril | 53 | 26 | 79 |
| 2024 Marzo | 66 | 33 | 99 |
| 2024 Febrero | 48 | 32 | 80 |
| 2024 Enero | 51 | 36 | 87 |
| 2023 Diciembre | 38 | 14 | 52 |
| 2023 Noviembre | 40 | 27 | 67 |
| 2023 Octubre | 43 | 21 | 64 |
| 2023 Septiembre | 66 | 27 | 93 |
| 2023 Agosto | 43 | 19 | 62 |
| 2023 Julio | 44 | 36 | 80 |
| 2023 Junio | 51 | 17 | 68 |
| 2023 Mayo | 61 | 24 | 85 |
| 2023 Abril | 50 | 20 | 70 |
| 2023 Marzo | 46 | 29 | 75 |
| 2023 Febrero | 49 | 21 | 70 |
| 2023 Enero | 38 | 24 | 62 |
| 2022 Diciembre | 37 | 29 | 66 |
| 2022 Noviembre | 17 | 24 | 41 |
| 2022 Octubre | 25 | 20 | 45 |
| 2022 Septiembre | 24 | 30 | 54 |
| 2022 Agosto | 25 | 29 | 54 |
| 2022 Julio | 20 | 27 | 47 |
| 2022 Junio | 24 | 20 | 44 |
| 2022 Mayo | 55 | 30 | 85 |
| 2022 Abril | 68 | 41 | 109 |
| 2022 Marzo | 67 | 37 | 104 |
| 2022 Febrero | 43 | 26 | 69 |
| 2022 Enero | 53 | 27 | 80 |
| 2021 Diciembre | 37 | 31 | 68 |
| 2021 Noviembre | 43 | 39 | 82 |
| 2021 Octubre | 46 | 39 | 85 |
| 2021 Septiembre | 34 | 36 | 70 |
| 2021 Agosto | 30 | 20 | 50 |
| 2021 Julio | 27 | 30 | 57 |
| 2021 Junio | 46 | 26 | 72 |
| 2021 Mayo | 27 | 19 | 46 |
| 2021 Abril | 74 | 40 | 114 |
| 2021 Marzo | 44 | 10 | 54 |
| 2021 Febrero | 44 | 22 | 66 |
| 2021 Enero | 28 | 10 | 38 |
| 2020 Diciembre | 24 | 10 | 34 |
| 2020 Noviembre | 23 | 11 | 34 |
| 2020 Octubre | 17 | 18 | 35 |
| 2020 Septiembre | 22 | 8 | 30 |
| 2020 Agosto | 32 | 16 | 48 |
| 2020 Julio | 24 | 8 | 32 |
| 2020 Junio | 45 | 18 | 63 |
| 2020 Mayo | 24 | 15 | 39 |
| 2020 Abril | 32 | 14 | 46 |
| 2020 Marzo | 25 | 14 | 39 |
| 2020 Febrero | 6 | 0 | 6 |
| 2020 Enero | 6 | 4 | 10 |
| 2019 Diciembre | 8 | 5 | 13 |
| 2019 Noviembre | 4 | 1 | 5 |
| 2019 Septiembre | 4 | 4 | 8 |
| 2019 Agosto | 4 | 1 | 5 |
| 2019 Julio | 4 | 1 | 5 |
| 2019 Junio | 4 | 1 | 5 |
| 2019 Mayo | 6 | 14 | 20 |
| 2019 Abril | 2 | 0 | 2 |
| 2019 Marzo | 4 | 6 | 10 |
| 2019 Febrero | 5 | 0 | 5 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Noviembre | 2 | 0 | 2 |
| 2018 Octubre | 3 | 0 | 3 |
| 2018 Septiembre | 4 | 0 | 4 |
| 2018 Julio | 0 | 1 | 1 |
| 2018 Junio | 0 | 1 | 1 |
| 2018 Mayo | 0 | 2 | 2 |
| 2018 Febrero | 22 | 1 | 23 |
| 2018 Enero | 33 | 5 | 38 |
| 2017 Diciembre | 37 | 4 | 41 |
| 2017 Noviembre | 17 | 6 | 23 |
| 2017 Octubre | 22 | 7 | 29 |
| 2017 Septiembre | 14 | 4 | 18 |
| 2017 Agosto | 19 | 7 | 26 |
| 2017 Julio | 13 | 4 | 17 |
| 2017 Junio | 26 | 16 | 42 |
| 2017 Mayo | 19 | 3 | 22 |
| 2017 Abril | 26 | 4 | 30 |
| 2017 Marzo | 13 | 43 | 56 |
| 2017 Febrero | 15 | 4 | 19 |
| 2017 Enero | 12 | 6 | 18 |
| 2016 Diciembre | 29 | 6 | 35 |
| 2016 Noviembre | 39 | 13 | 52 |
| 2016 Octubre | 29 | 6 | 35 |
| 2016 Septiembre | 0 | 8 | 8 |
| 2016 Julio | 8 | 1 | 9 |
| 2016 Junio | 9 | 5 | 14 |
| 2016 Mayo | 6 | 19 | 25 |
| 2016 Abril | 6 | 13 | 19 |
| 2016 Marzo | 2 | 18 | 20 |
| 2016 Febrero | 0 | 13 | 13 |
| 2016 Enero | 13 | 13 | 26 |
| 2015 Diciembre | 3 | 5 | 8 |
| 2015 Noviembre | 5 | 1 | 6 |
| 2015 Octubre | 1 | 0 | 1 |
| 2015 Septiembre | 0 | 4 | 4 |
| 2015 Agosto | 0 | 1 | 1 |
| 2015 Julio | 3 | 3 | 6 |
| 2015 Junio | 1 | 1 | 2 |
| 2015 Mayo | 2 | 5 | 7 |
| 2015 Abril | 1 | 16 | 17 |
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