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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 21  |  Issue : 3  |  Page : 203-205

Annular pattern of generalized granuloma annulare in an infant


1 Department of Dermatology, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Pathology Kolkata Reference Lab, SRL Ltd., Kolkata, West Bengal, India
3 Department of Pediatric Dermatology, Institute of Child Health, Kolkata, West Bengal, India

Date of Submission10-Feb-2020
Date of Decision13-Feb-2020
Date of Acceptance14-Apr-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Dr. Swetalina Pradhan
Department of Dermatology, All India Institute of Medical Sciences, Patna - 801 505, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_20_20

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  Abstract 


Granuloma annulare (GA) is a benign granulomatous dermatosis. Clinically, it has been classified into localized, generalized, subcutaneous, macular, erythematous, and perforating types. Generalized GA (GGA) is an unusual pattern of GA reported mostly in adults aged 50 years or over and children aged about 10 years. Occurrence in infants is very rare and few cases of papular GGA have been reported in infants. We report a case of annular pattern of GGA in a 3-month-old infant. This is the first case report of annular pattern GGA in an infant.

Keywords: Annular pattern, generalized, granuloma annulare, infant


How to cite this article:
Pradhan S, Dhar S, Dhar S, Singh RK. Annular pattern of generalized granuloma annulare in an infant. Indian J Paediatr Dermatol 2020;21:203-5

How to cite this URL:
Pradhan S, Dhar S, Dhar S, Singh RK. Annular pattern of generalized granuloma annulare in an infant. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Jul 10];21:203-5. Available from: http://www.ijpd.in/text.asp?2020/21/3/203/288495




  Introduction Top


Granuloma annulare (GA) has been classified into localized, generalized, subcutaneous, macular, erythematous, and perforating types. Generalized GA (GGA) is an unusual subtype constituting 8%–15% of all types of GA and has been reported mostly in adults aged 50 years or over and children aged about 10 years.[1],[2] Occurrence in infants is very rare. Handful cases of papular GGA have been reported in infants. We report a case of annular pattern of GGA in a 3-month-old infant.


  Case Report Top


A 3-month-old male infant presented with a history of generalized asymptomatic papules and annular plaques over the bilateral upper limb and lower limb, buttocks, scalp, and shoulders for 2 months [Figure 1] and [Figure 2]. The lesions first appeared at the age of 1 month, beginning at the occiput area along with few lesions on the thighs and gradually involved other areas of thighs, buttocks, extremities, and upper trunk. To begin with, the lesions were papular and later on his mother noticed annular plaques. The child was born out of nonconsanguineous parentage and normal vaginal delivery. Birth was uneventful. Dermatological examination revealed few slightly erythematous firm papules over the scalp, upper trunk and extremities. Majority of the lesions were annular plaques with central clearing over scalp, shoulders, bilateral upper limbs, lower limbs, and buttocks with predilection for trauma-prone areas [Figure 1] and [Figure 2]. Close examination showed that the margins of the plaques were formed by closely apposed papules. Histopathological reports showed necrobiotic granuloma with palisading of histiocytes around degenerated collagen and multinucleate giant cells [Figure 3]. Hence, the patient was diagnosed to have annular pattern of GGA based on clinical and histopathological findings. The patient was prescribed topical desonide ointment over the lesions and after 1 month the lesions healed completely [Figure 4].
Figure 1: (a) Annular plaques and papules of granuloma annulare over the right elbow, hand, and right knee (b) Annular GA plaques over the right arm and forearm (c) Papules and annular plaque of GA over the left elbow and arm (d) Annular plaques of GA over the bilateral thighs

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Figure 2: Papules and annular plaques of GA over the buttock

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Figure 3: (a) Scanner view H and E stain: Necrobiotic granuloma in superficial and middermis (b) 10X, H and E stain: Palisaded histiocytes arranged around degenerated collagen (c) 10X, H and E stain: Tiered arrangement of histiocytes (d) 49X, H and E: Multinucleate giant cell with histiocytes and degenerated collagen

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Figure 4: (a-c) Complete improvement following treatment

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  Discussion Top


GA is a benign, asymptomatic granulomatous cutaneous disease which presents as multiple skin-colored, firm, smooth papules to annular plaques. Clinically, it has been classified into localized, generalized, subcutaneous, macular, erythematous, and perforating type. Among all, GGA is a rare pattern and is defined by distribution of lesions over at least trunk and the upper, lower, or both the extremities. Morphologically, GGA has been classified into papular and annular type.[3] Papular pattern is common compared to the annular pattern GCA.[3]

GGA is characterized by onset in old age mainly and less commonly in children. Rarely, it has been reported in infants. Choi et al. have reported a case of perforating GGA in a 68-day-old girl, which was of papular pattern.[4] Lee et al. reported a case of papular GGA in a 3-month-old girl which occurred following Bacillus Calmette–Guérin (BCG) vaccination.[5] Similarly, two cases of papular GGA have been reported by Hwang et al. in male infants.[3] The index is 3 month old infant with both papular and annular lesions of GA, predominant morphology being annular. Association with insect bite, trauma, BCG vaccination, chronic hepatitis C, hepatitis B, diphtheria/tetanus vaccination, acquired immunodeficiency syndrome, diabetes, and thyroid disease has been reported in GGA.[5] No such association was present in our case.

Clinical diagnosis of GA is usually confirmed by histopathology. Necrobiotic granuloma is the most characteristic histological lesion in GA; however, three histological patterns have been described: (i) necrobiotic palisading granulomas; (ii) an interstitial form; and (iii) granulomas of sarcoidal or tuberculoid type.[6] Necrobiotic palisading granulomas are situated in the superficial and middermis separated by relatively normal tissue. They are characterized by foci of necrobiosis surrounded by histiocytes and lymphocytes, with the histiocytes commonly forming a palisaded pattern. There are varying numbers of multinucleate giant cells in this peripheral zone.[6]

GGA shows very poor response to therapy except the localized type. Various treatments, such as systemic/topical steroids, cyclosporine, psoralen and ultraviolet A therapy (PUVA), retinoid, antimalarial agents, and dapsone, have been tried with little to moderate success.[5] Our case presented with combination of papular and annular pattern of GGA with annular pattern being predominant it was clinically diagnosed as GGA based on the widespread distribution of lesions and confirmed by histopathology. The patient was treated with topical desonide following which the lesions improved completely after 1 month. Review of English literature did not show any reported case of annular pattern GGA in an infant and we believe our case being the first report of such presentation.

Declaration of patient consent

Authors certify that they have obtained all appropriate patient consent forms. In the form the parents have given their images and other clinical informations to be reported in the journal. The parents understand that their child's name and initial will not be published and due efforts will be made to conceal his identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kim YJ, Kim YC, Lee ES, Kang HY. A case of generalized granuloma annulare in infant. Korean J Dermatol 2006;44:645-7.  Back to cited text no. 1
    
2.
Yun JH, Lee JY, Kim MK, Seo YJ, Kim MH, Cho KH, et al. Clinical and pathological features of generalized granuloma annulare with their correlation: A retrospective multicenter study in Korea. Ann Dermatol 2009;21:113-9.  Back to cited text no. 2
    
3.
Hwang SW, Oh DJ, Cho KJ, Lee D, Kim JW, Park SW. Two case of granuloma annulare in infants. Ann Dermatol Seoul 2007;19:122-5.  Back to cited text no. 3
    
4.
Choi JC, Bae JY, Cho S, Choi JH, Sung KJ, Moon KC, et al. Generalised perforating granuloma annulare in an infant. Pediatric Dermatol 2003;20:131-3.  Back to cited text no. 4
    
5.
Lee SW, Cheong SH, Byun JY, Choi YW, Choi HY, Myung KB. Generalied granuloma annulare in infancy after BCG vaccination. Ann Dermatol 2011;23:319-21.  Back to cited text no. 5
    
6.
Piette EW, Rosenbach M. Granuloma annulare: Clinical and histologic variants, epidemiology, and genetics. J Am Acad Dermatol 2016;75:457-65.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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