Quiz 52: What is your diagnosis?

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Diagnosis: Quiz 52

Quiz 52

Answer: Granuloma annulare

Criteria for diagnosis clinically: Arcuate and annular, smooth-surfaced, burgundy-colored plaques are those of granuloma annulare.

Differential diagnosis clinically: There really is none, although the possibility of an unusual tumid expression of lupus erythematosus or even mycosis fungoides could be considered fleetingly. Biopsy should be confirmatory of granuloma annulare.

Criteria for diagnosis histopathologically: The findings in a locus in the upper half of the dermis of epithelioid histiocytes, some of them multinucleate in palisaded array, as well as in arrangement interstitial, in the center of which are both degeneration of collagen and deposits of mucin accompanied by a sparse perivascular infiltrate of lymphocytes, are those of granuloma annulare.

Differential diagnosis histopathologically: There is none.

Clinicopathologic correlation: The plaque is formed mostly of the infiltrate of histiocytes, the redness is a consequence of venules in the upper part of the dermis having been dilated widely and filled, in vivo,  with erythrocytes, and the surface is smooth because the stratum corneum is normal.

Options for therapy predicated on knowledge of histopathologic findings: Once a clinician receives a diagnosis from a histopathologist of granuloma annulare, an inference can be made that it is only a matter of time before lesions begin to involute and disappear. If the patient wishes the process of involution to be expedited, that can be accomplished by intralesional injection of corticosteroid.

1) The attributes, clinical and histopathologic, pictured here are stereotypical of one expression of granuloma annulare. Clinically, the plaques are large and both annular and arcuate; histopathologically, the epithelioid histiocytes are organized in patterns palisaded and interstitial. Parenthetically, the lesions were bilateral, as so often is the situation for granuloma annulare.

2) It sometimes is difficult in sections stained by hematoxylin and eosin to distinguish between degeneration of collagen and mucin when they are present together in the center of a palisade of epithelioid histiocytes, that challenge to discrimination being evident here. The degenerate collagen bundles, slightly eosinophilic, have a smudged appearance, whereas the mucin, slightly basophilic, appears as subtly granular material that is seen to much better advantage in a stain specialized for it, such as alcian blue.

3) The focality of the granulomatous inflammation in this section of tissue is characteristic of granuloma annulare. Not uncommonly, in a section cut from a 4 mm punched-out biopsy specimen, several distinct granulomatous loci can be observed at different levels of the reticular dermis. The discreteness of the zones of granulomatous inflammation is one of several findings that enable granuloma annulare to be distinguished from necrobiosis lipoidica.

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