A RARE CASE OF GENERALIZED GRANULOMA ANNULARE THAT RESEMBLE WITH ERYTHEMA ANNULARE CENTRIFUGUM.

41
Majalah Kedokteran Andalas
No.1. Vol.29. Januari – Juni 2005

A RARE CASE OF
GENERALIZED
GRANULOMA
ANNULARE THAT
RESEMBLE WITH
ERYTHEMA
ANNULARE
CENTRIFUGUM
Fitra Deny*, Sri Lestari,KS*,
Isramiharti*, Zainal H*, Salmiah A **
*Bagian Ilmu Kulit & Kelamin FK
UNAND / RS Dr. M. Djamil Padang
**Bagian Patologi Anatomi FK
UNAND/RS. Dr. M. Djamil Padang

Abstract
A case of granuloma annulare

of 16- year- old is reported. The
patient had numerous annular plagues
that coalesce form arcuate or
polycyclic pattern with raised border
since 1 month ago with unknown
causes. Histopathology examination
revealed perivascular lymphocytes
infiltrate, degenerated of collagen,
interstitial and slight palisaded
lymphohistiocytes arrangements in
dermis.
Granuloma annulare (GA) is a
self-limited and uncommon cutaneous
disease. Clinically mimicking with
some of dermatoses with annular
configuration. The chief aid in the

LAPORAN KASUS

diagnosis of granuloma annulare is

biopsy.
Key word : granuloma annulare,
palisaded
lympohistiocytes
arrangements

ABSTRACT
A case of granuloma annulare of
16-year-old is reported. The patient had
numerous annular plagues that coalesce
form arcuate or polycyclic pattern with
raised border since 1 month ago with
unknown
causes.
Histopathology
examination revealed perivascular
lymphocytes infiltrate, degenerated of
collagen,
interstitial
and

slight
palisaded
lymphohistiocytes
arrangements in dermis.
Granuloma annulare (GA) is a selflimited and uncommon cutaneous
disease. Clinically mimicking with
some of dermatoses with annular
configuration. The chief aid in the
diagnosis of granuloma annulare is
biopsy.
Key words : granuloma annulare,
palisaded
lympohistiocytes
arrangements

Majalah Kedokteran Andalas No. 1. Vol.29. Januari – Juni 2005

42
Majalah Kedokteran Andalas
No.1. Vol.29. Januari – Juni 2005


Majalah Kedokteran Andalas No. 1. Vol.29. Januari – Juni 2005

42
Majalah Kedokteran Andalas
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INTRODUCT
ION
Granuloma
Annulare (GA)
is a benign,
usually
selflimited
dermatoses of
unknown
etiology, which
clinical
characteristics
with

annular
plaques to form
arciform
configuration
with
raised
(1-4)
border.
GA
is
an
uncommon
cutaneous
disease.(4,5) GA
is
most
common
in
children
and

young adults.(3)
Trauma, insect
bite reactions,
tuberculin
testing,
sun
exposure,
PUVA therapy
and
viral
infections have
all
been
proposed
as
inciting factors.
(6)

GA
can

present
with
clinical variants
are : Localized
GA
with
characteristics
most common

appears
in
dorsal of hand
and feet with
solitary lesion.
In generalized
GA
usually
appears more
than
ten

lesions, involve
the trunk and
the
lesions
predominantly
on extensor of
extremities,
symmetry. In
sub-cutaneous
GA,
lesions
usually
are
nodules, may
be solitary or
multiple
lesions, usually
mith diabetes
or
abnormal

glucose
tolerance.
In
perforating
GA, the lesions
appears
as
small papules
with
central
umbilication,
plugs
and
(1,2,4,7)
crusts.
The
pathogenesis of
granuloma
annulare
is

obscure.
Proposed
pathogenic
mechanisms
include
cell
mediated
immunity (type

IV), immune
complex
vasculitis and
abnormality of
tissue
monocytes but
none
has
convincing
supporting.(4) A
viral

or
vascular
etiology
are
among many
that have been
suggested over
the years.(8)
Generally,
patients with
granuloma
annulare are in
good health. A
relationship of
granuloma
annulare to the
other diseases
like
diabetes
mellitus,
necrobiosis
lipoidica
diabeticorum
and rhemathoid
nodules
has
been
widely
discussed, but
no
firmly
established.(2)
The
clinical
features
presented firm,
smooth, shiny
dermal papules
that
often
coalesce
to
form annular
plaques
with

Majalah Kedokteran Andalas No. 1. Vol.29. Januari – Juni 2005

raised
erythematous
borders,
1-5
cm, painless,
skin coloured–
violaceous,
soliter
or
multiple, dome
shaped, annular
arciform.(1,2,4)
Lesions most
commonly
manifest on the
dorsal surfaces
of the feet,
hand
and
fingers and on
the
extensor
aspects of the
arms and legs.
(4)

The chief
aid
in
the
diagnosis
of
granuloma
annulare
is
(1,9)
biopsy.
The
results of blood
and urinalysis
tests
are
usually normal.
(1)
The basic
histopatology
picture
is
characterized
by the presence
in the dermis of
small or large
foci collagen
degeneration
surrounded by
a
lymphohistiocy
tic
infltrate
composed

43
Majalah Kedokteran Andalas
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mostly
histiocytes in a
palisading
arrangement.
(1,2,10)
mucin
deposition. The
mucinous
material can be
identified
by
special stains,
colloidal iron,
toluidine blue,
etc.(1,2,4,10)
Differentia
l diagnosis of
annular lesions
are
dermatophytosi
s,
erythema
annulare
centrifugum,
porokeratosis
Mibelli
sarcoidosis,
annular lichen
planus, other
palisading
granulomas
(necrobiosis
lipoidica,
rheumatoid
nodule, actinic
ganuloma).(1.2,4)
Erythema
Annulare
Centrigugum
(ECA)
is
eruption with
annular
erythematous
plagues
with
trailing scale
that
form
arciform
or
polycyclic in

configuration
with
raised
borders.
Histopathology
revealed coatsleeves
perivascular
lymphocytes
infiltrate. (11,12)
Porokeratosis
Mibelli
uncommon
disease
that
may occur any
where on the
body
with
characteristic
lesion
is
annular plaques
with
welldemarcated
raised
hyperkeratotic
border
with
central atrophy.
(13)

Although
the
disease
usually
selflimited,
clinicians have
use a wide
array
of
treatment
method
to
hasten
resolution,
these include :
glucocorticoid
topical
an
intralesions,
tacrolimus
ointment,
imiquimod
cream, psoralen

plus
PUVA,
narrow
band
UVB,
isotretinoin,
dapson,
chloroquin,
nicotinamide,
niacinamide,
vitamine E.(2,
4,14)

CASE
A 16-yearold
of
adolescent boy
came to the
DermatoVenereology
Department out
patient Dr. M.
Djamil
Hospital
on
March
31th,
2005
with
numerous
annular redishviolaceous
patches
scattered
at
over the arms
since 1 month
ago.
Present illness
history
There were
sharply
demarcated
redishviolaceous
patches
with
raised irregular
border
scattered
at
both of arms

Majalah Kedokteran Andalas No. 1. Vol.29. Januari – Juni 2005

since 1 month
ago.
Initially,
the
patches
were
only
insect
bite
lesions-like on
his left upper
arm and later
became
enlarged
and
numerous then
spreaded fast
to both of the
arms
and
lateral chests.
Some times he
felt itchy but it
wasnot intents.
He got some
medicines from
phycisians, but
no
improvements.
His medicines
were
anti
histamine and
ointment
(he
forgot
what
name
of
ointment).
There was no
history of taken
of medicines,
regarding diets,
fever, trauma,
excessive sun
exposure,
weight
loss,
hepatitis
history
and
complaints
associated with
his
joints
before. There

44
Majalah Kedokteran Andalas
No.1. Vol.29. Januari – Juni 2005

were no history
of
urticaria,
allergic of food
before.
There were
no
family
suffered from
this
disease,
diabetic
history, others
cancers,
and
rheumatoid
disease.
General
examinations
were in normal
limits.
Dermatologyc
al state :
On
the
lateral chests,
both of arms,
predominantly
on the extensor
surface
revealed
numerous
lesions which
bilaterally
disseminated
distribution,
The
lesions
varied
in
shapes,
annular, ellips,
and some may
convert
into
polycyclic or
arcuate forms.
The
lesions
consisted
of
erythematousbrownish
papules, well-

demarcated
annular redishviolaceous
plaques
with
raised borders
that
some
coalescence
form
arcuate
pattern.
This
borders
consisted
of
violeaceous
papules
that
arranged
a
treadlike
groove.
The
lesions varied
in sizes, millier,
lenticular
to
plaque with the
central
pinkviolaceouos
coloured. On
some
of
patches
revealed scales.
The
surrounding
tissue
of
lesions
were
normal
Mucous
membranes
were in normal
limits.
Test
of
sensibility
There were no
hypoesthesia or
anesthesia.

annular
e
centrifu
gum.
 Poroker
atosis
Mibelli.
 Annular
lichen
planus.
 Tinea
corporis
.
Suggestion :
Histopatho
logy
examinatio
n
Blood and
urynalysis
examinatio
n
Skin
scraping with
KOH 10%

Working
diagnosis :
Granuloma
annulare
Differensial
diagnosis :
 Erythe
ma

Majalah Kedokteran Andalas No. 1. Vol.29. Januari – Juni 2005

Laboratory
finding
Blood
examination :
Hb
:
12,3 gr%.
Leucocyte
: 8300/mm3.
ESR
:
21/1.
Ht
:37%.
Thrombocyte :
434.000/mm3.
Diff Count
:
0/2/3/68/26/1

45
Majalah Kedokteran Andalas
No.1. Vol.29. Januari – Juni 2005

Sugar blood
98
SGPT
16.
SGOT
: 15.
Rheumatoid
factor
Negative.

:
:

:

Urinalysis tests
Protein
:Negati
ve.
Reduction
:
Negative.
Leucocyte
:04/mm2.
Erythrocyte :
0-1/ mm2.
Result
skin
scrapping with
KOH
10%
examination :
Hypha or
spora
were
negative
Result
of
histopathology
examination
Epidermis
Focal
parakeratosis,
slightly
acanthosis
Dermis
:
Perivascul
ar
mono
nuclear
infiltrate with
slight collagen
degeneration of

dermis
and
some
loose
connective
tissue
area.
Discrete foci of
lymphohistiocy
tes within the
dermis in slight
palisaded
arrangement,
epitheloid cells.
Subcutane
ous There were
no abnormality.
This features
supported
to
granuloma
annulare

Prognosis
Qu
o
ad
vita
m
:
Bo
na
m
Qu
o
ad
san
am

Diagnosis
Granuloma
annulare
Suggestion :
specific
staining
for
mucin
Treatment :
:
- Explaination to patient that this
- Topical
:
flucinolon cr
5%

Majalah Kedokteran Andalas No. 1. Vol.29. Januari – Juni 2005

:
dub
ia
ad
bon
am
Qu
o
ad
cos
met
icu
m
:
Bo
na
m
Quo
ad
fungsionam :
Bonam
DISCUSSION
GA is
uncommon
dermatosis

46
Majalah Kedokteran Andalas
No.1. Vol.29. Januari – Juni 2005

whose
frequency
in
the
general
population is
unknown.
In
Dr. M. Djamil
Hospital
Padang, this is
first case that
has
been
reported. The
type of GA was
generalized
GA, because of
we found more
than
ten
lesions. Only
15% of GA
with this type.
Diagnosis
of
this
disease
based on :
- Mildly
pruritic
lesions
and usually
occur
in
young
adult
- Spontaneo
us
remmision
- Lesions
consisted
of papules
that
coalescenc
e to form
annular
plaques
with raised
borders.
Histopathol
ogy

examinatio
n
:
characterist
ic
appearance
s of this
disease
were
mucinous
areas that
be
surrounded
by
palisaded
lympho
histiocytes
or
histiocytes
present just
an
interstitial
pattern,
perivascula
r
lymphocyte
s infiltrate,
collagen
degeneratio
n.
Differe
ntial diagnosis
was Erythema
Annular
Centrifugum
(ECA)
or
erythema
gyratum
perstans. Signs
and symptoms
of this disease
included :
History of
hypersensitivit
y

-

mildly
pruritus
and
can
occur any
age.
Spontaheous
remmision.
- Lesions
begin as
erythemat
ous
macules
or
urticarial
papules
and
enlarged
to form
arciform
or
polycycli
c
in
configurat
ion with
raised
borders
and
central
clearing
with
trailing
scale.
Histopath
ology
revealed
focal
spongiosi
s
and
focal
parakerat
osis,
‘coatsleeves-

Majalah Kedokteran Andalas No. 1. Vol.29. Januari – Juni 2005

like’
perivascul
ar
lymphocy
tic
infiltrate.
In
this
patient,
clinically we
found lesions
consisted
of
papules
that
coalescence to
annular plaques
with scale, but
not
trailing
scale.
The
borders of the
lesions
were
brownish,
in
ECA usually
erythematous.
Histopathology
finding
revealed slight
spongiosis,
focal
parakeratosis,
perivascular
lymphocytes
infiltrate, slight
palisaded
lymphohistiocy
tes
array,
degenerated of
collagen.
It may because
of course of
disease
and
process
of
preparating
staining,
we
could
not
identify mucin

47
Majalah Kedokteran Andalas
No.1. Vol.29. Januari – Juni 2005

deposition. It
can
be
identified with
specific
staining
for
mucinous
material such
as alcian blue
or
colloidal
iron.
We did not
found
the
palisaded
histiocytes. In
literatures
mentions that
we could find
the features of
GA
with
unpalisaded,
slight palisaded
and
well
palisaded
histiocytes that
surrounding the
degeneration
areas,
occasionally
sections
will
not
reveal
increased
mucin
particularly
those lacking a
palisaded
arrangement of
histiocytes. On
rare occasions
there
are
aggregations of
epitheliod
histiocytes.(10)
Because of this
reason.
Diagnosis
of

this
patient
tends
to
granuloma
annulare. But
by
mucin
preparation
staining it will
support
to
diagnosis.
Other
differential
diagnosis were
porokeratosis
Mibelli
and
annular lichen
planus.
Porokeratosis
Mibelli based
on
clinical
appearances
will be found
annular plaques
with
welldemarcated
raised
hyperkeratotic
borders contain
a
threadlikegroove much
like dike split
by
a
longitudinal
furrow.
Histopathology
examination
will be found
cornoid lamella
(keratin-filled
invagination).
In
annular lichen
planus included
intent pruritus,
small papules
with network

of white lines
and
histopathologic
ally revealed a
band-like
dermal
lymphocytic
infiltrate and
saw-tooth
appearances as
a hallmark. By
histo-pathology
we
could
exclude both of
this diseases.
Because
of the etiology
is unknown, its
difficult to give
the
suitable
therapy.
By
topical
corticosteroid,
there
were
significant
improvements
in 4 weeks.
Prognosis
of
this
disease
was good with
spontaneous
remmision but
it
can
be
exacerbation.
KEPUSTAKA
AN
1. Moschel
la LM,
Cropley
TG.
Disease
of
the
mononu
clear

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c
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la
SL,
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HJ, eds.
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WB
Saunders
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Granulo
ma
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