Case and Research Letters
Pseudolymphomatous Granuloma Annulare: A Little-Known Variant
Granuloma anular pseudolinfomatoso: una variante poco conocida
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Llamas-Velasco, A. Urquina-Renke, A. Pérez-Plaza, J. Fraga" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Llamas-Velasco" "email" => array:1 [ 0 => "mar.llamasvelasco@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" => "A." "apellidos" => "Urquina-Renke" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Pérez-Plaza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Fraga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Universitario de la Princesa, Madrid, España" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Anatomía Patológica, Hospital Universitario de la Princesa, Madrid, España" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Granuloma anular pseudolinfomatoso: una variante poco conocida" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 564 "Ancho" => 850 "Tamanyo" => 50613 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Arciform lesion on the right forearm. Erythematous 0.8-cm plaque with a central crust about 4<span class="elsevierStyleHsp" style=""></span>cm from the main lesion.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Granuloma annulare (GA) is a dermatosis of unknown origin that has 3 characteristic histopathologic patterns: <span class="elsevierStyleItalic">1</span>) necrobiotic granulomas in the mid-superficial dermis with 1 or more areas of necrobiosis with increased mucin deposition surrounded by histiocytes and lymphocytes, <span class="elsevierStyleItalic">2</span>) interstitial (incomplete) form with increased lymphocytes and histiocytes among collagen bundles separated by mucin, and <span class="elsevierStyleItalic">3</span>) tuberculoid or sarcoid granulomas.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Clinical variants include localized, generalized, perforating, and subcutaneous GA, in addition to rarer variants such as palmar-plantar and patch forms.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Localized GA is the most characteristic form and consists of ring-like pink or reddish papules and plaques, without an epidermal component, normally located on the extremities.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Of note among the histopathologic variants of GA are elastolytic granulomas, but GA may also occur in association with eccrine squamous syringometaplasia, mid-dermal elastolysis, and even vasculitis and neutrophils.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Pseudolymphomatous GA is a more recently described variant.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We report on a case of GA with pseudolymphomatous infiltrates as determined by histology.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">An 82-year-old man with a history of hypertension, dilated myocardiopathy, and prostate cancer presented with a pruritic lesion of 1 year's duration on the dorsum of his right forearm. The physical examination showed erythematous papules that converged to form an arciform, nonindurated plaque measuring 5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Biopsy showed an interstitial lymphocytic and histiocytic infiltrate accompanied by a prominent perivascular lymphocytic infiltrate without atypical cells. Alcian blue staining showed increased interstitial mucin deposition (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A-C and <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A). Immunohistochemically, the perivascular infiltrate was formed by a mixture of CD4<span class="elsevierStyleSup">+</span> and CD8<span class="elsevierStyleSup">+</span> lymphocytes with numerous CD163<span class="elsevierStyleSup">+</span> and CD68<span class="elsevierStyleSup">+</span> cells among the collagen bundles (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B-D). Groups of CD123-expressing dendritic plasmacytoid cells were not observed. Based on the clinical and histopathologic findings, a diagnosis of pseudolymphomatous GA was established. The lesion resolved completely after a month's application of topical propionate clobetasol 0.05% cream and there have been no recurrences to date. Pseudolymphomatous GA, which was described by Cota et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> in 2012, is histopathologically characterized by a dense lymphocytic infiltrate around the superficial and deep vessels, an absence of atypical lymphocytes, and concomitant interstitial or necrobiotic GA. The clinical findings in this first series of pseudolymphomatous GA suggested highly varied diagnoses (pseudolymphomas, mycosis, lichenoid dermatitis, sarcoidosis, papular dermatitis, plaque parapsoriasis, and figurate erythema), and an initial diagnosis of GA based on clinical findings was only made in 3 cases. Sixty percent of the patients had localized lesions similar to the one seen in our patient. The histopathologic differential diagnosis should include lymphoid hyperplasia, lupus tumidus (which can be ruled out by clinical findings and an interstitial pattern on biopsy), interstitial mycosis fungoides (histopathologic variant of mycosis fungoides characterized by lymphocytes scattered among collagen fibers and in which there are never more interstitial macrophages than lymphocytes), and interstitial granulomatous drug reaction, which we excluded based on the patient's history.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">There have also been reports of granulomatous infiltrates, which can appear alongside specific atypical tumor cells, both in Hodgkin and non-Hodgkin lymphomas and in some solid tumors.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3,4</span></a> In our patient, we were able to exclude this possibility with a high level of certainty given the rapid resolution of the lesion (typical in localized GA), the characteristic clinical findings, and the absence of concomitant disease. The association between GA and malignant tumors is probably fortuitous.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> There have also been reports of GA coexisting with lymphoid disorders, such as adult T-cell leukemia/lymphoma,<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3,6</span></a> acute myeloid leukemia, and primary cutaneous small to medium CD4<span class="elsevierStyleSup">+</span> T-cell lymphoma.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Sarcoidosis and lymphoma could also be included in this second group, which we could consider to be nonspecific manifestations of lymphomas. A diagnosis of pseudolymphomatous GA should therefore be based on the integration of clinical and pathologic findings and be supported by immunohistochemical studies to rule out lymphoma and other tumors, particularly if atypical cells are observed. Serology and <span class="elsevierStyleItalic">Borrelia</span> polymerase chain reaction detection should also be performed to rule out borreliosis in endemic areas or in patients with compatible clinical manifestations. A diagnosis of pseudolymphomatous GA must be contemplated in cases of interstitial GA or GA with necrobiotic granulomas when a dense superficial and deep lymphoid infiltrate is observed. Pseudolymphomatous GA is rare and only a few cases have been reported in the literature. Familiarity with this entity is important to prevent overtreatment and unnecessary tests.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of Interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of Interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-07-29" "fechaAceptado" => "2017-10-22" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Llamas-Velasco M, Urquina-Renke A, Pérez-Plaza A, Fraga J. Pseudolymphomatous Granuloma Annulare: A Little-Known Variant. Actas Dermosifiliogr. 2019;110:162–164.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 564 "Ancho" => 850 "Tamanyo" => 50613 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Arciform lesion on the right forearm. Erythematous 0.8-cm plaque with a central crust about 4<span class="elsevierStyleHsp" style=""></span>cm from the main lesion.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1979 "Ancho" => 2334 "Tamanyo" => 1235449 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Dense superficial and deep perivascular infiltrate with necrobiotic areas in the center. B, Detail of small perivascular lymphocytes and interstitial lymphocytes and histiocytes. C, Detail of central necrobiosis.</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" => 1750 "Ancho" => 2334 "Tamanyo" => 689367 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A, Panoramic view of lesion with Alcian blue staining. B, Panoramic view showing the mainly perivascular distribution of CD3<span class="elsevierStyleSup">+</span> lymphocytes. C, Panoramic view showing that most T-cell lymphocytes stain positive for CD4. D, Staining with CD68 showing the presence of interstitial macrophages.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Granuloma annulare with prominent lymphoid infiltrates (“pseudolymphomatous” granuloma annulare)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Cota" 1 => "G. Ferrara" 2 => "L. Cerroni" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/DAD.0b013e31822a2aca" "Revista" => array:7 [ "tituloSerie" => "Am J Dermatopathol." 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 9 | 10 | 19 |
| 2024 Octubre | 104 | 67 | 171 |
| 2024 Septiembre | 91 | 50 | 141 |
| 2024 Agosto | 124 | 63 | 187 |
| 2024 Julio | 119 | 51 | 170 |
| 2024 Junio | 90 | 43 | 133 |
| 2024 Mayo | 98 | 40 | 138 |
| 2024 Abril | 99 | 48 | 147 |
| 2024 Marzo | 97 | 31 | 128 |
| 2024 Febrero | 76 | 58 | 134 |
| 2024 Enero | 98 | 39 | 137 |
| 2023 Diciembre | 84 | 32 | 116 |
| 2023 Noviembre | 94 | 54 | 148 |
| 2023 Octubre | 98 | 48 | 146 |
| 2023 Septiembre | 91 | 34 | 125 |
| 2023 Agosto | 71 | 24 | 95 |
| 2023 Julio | 134 | 42 | 176 |
| 2023 Junio | 84 | 36 | 120 |
| 2023 Mayo | 86 | 23 | 109 |
| 2023 Abril | 57 | 30 | 87 |
| 2023 Marzo | 83 | 25 | 108 |
| 2023 Febrero | 62 | 24 | 86 |
| 2023 Enero | 50 | 27 | 77 |
| 2022 Diciembre | 75 | 42 | 117 |
| 2022 Noviembre | 48 | 35 | 83 |
| 2022 Octubre | 34 | 29 | 63 |
| 2022 Septiembre | 36 | 31 | 67 |
| 2022 Agosto | 68 | 42 | 110 |
| 2022 Julio | 90 | 47 | 137 |
| 2022 Junio | 34 | 28 | 62 |
| 2022 Mayo | 87 | 44 | 131 |
| 2022 Abril | 60 | 24 | 84 |
| 2022 Marzo | 70 | 59 | 129 |
| 2022 Febrero | 70 | 26 | 96 |
| 2022 Enero | 75 | 36 | 111 |
| 2021 Diciembre | 47 | 32 | 79 |
| 2021 Noviembre | 54 | 52 | 106 |
| 2021 Octubre | 70 | 62 | 132 |
| 2021 Septiembre | 51 | 39 | 90 |
| 2021 Agosto | 40 | 36 | 76 |
| 2021 Julio | 44 | 23 | 67 |
| 2021 Junio | 47 | 19 | 66 |
| 2021 Mayo | 72 | 36 | 108 |
| 2021 Abril | 124 | 72 | 196 |
| 2021 Marzo | 82 | 38 | 120 |
| 2021 Febrero | 77 | 26 | 103 |
| 2021 Enero | 51 | 13 | 64 |
| 2020 Diciembre | 47 | 14 | 61 |
| 2020 Noviembre | 27 | 14 | 41 |
| 2020 Octubre | 25 | 18 | 43 |
| 2020 Septiembre | 35 | 10 | 45 |
| 2020 Agosto | 25 | 22 | 47 |
| 2020 Julio | 26 | 10 | 36 |
| 2020 Junio | 27 | 21 | 48 |
| 2020 Mayo | 16 | 15 | 31 |
| 2020 Abril | 20 | 12 | 32 |
| 2020 Marzo | 16 | 6 | 22 |
| 2020 Febrero | 1 | 0 | 1 |
| 2019 Mayo | 1 | 0 | 1 |
| 2019 Febrero | 2 | 0 | 2 |
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