May 21, 2014
10:21:16am
WSPC/135-HS
FA1
1472022
Hand Surgery, Vol. 19, No. 2 (2014) 257–259 © World Scientific Publishing Company DOI: 10.1142/S0218810414720228
ATYPICAL SUBCUTANEOUS GRANULOMA ANNULARE ON THE DIGIT: A CASE REPORT Kazufumi Sano,* Kazumoto Katagiri† and Satoru Ozeki* *Department
of Orthopaedic Surgery
Hand Surg. 2014.19:257-259. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 02/01/15. For personal use only.
†
Department of Dermatology Dokkyo Medical University Koshigaya Hospital Saitama 343-8555, Japan Received 31 October 2013; Revised 28 November 2013; Accepted 28 November 2013 ABSTRACT Subcutaneous granuloma annulare is a benign inflammatory disorder consisting of deep dermal or subcutaneous nodules, and frequently occurring in the extremities and scalp in children. The occurrence of aggregated multiple nodules in a digit is quite atypical. This is a report of an eight-year-old girl who presented with increasingly asymptomatic multiple nodules on her middle finger over a period of six months. Definitive diagnosis of subcutaneous granuloma annulare was achieved with surgical biopsy and no aggressive growth subsequently and showed a tendency toward spontaneous resolution. Keywords: Subcutaneous Granuloma Annulare; Subcutaneous Nodule; Tumour-like Lesion; Finger Nodule.
INTRODUCTION
finger. The surface of the mass was smooth to the touch and adhesion between the mass and its overlying skin was not identified, but mobility in relation to the underlying tissue was limited. No skin lesion was identified over the mass. Range of motion of the middle finger was not disturbed. Radiographs revealed normal findings. MR images showed that the masses were homogenous lower signal intensity on a T1-weighted image, and high signal intensity on a fast spin-echo T2weighted image obtained with fat saturation (Figs. 2A and 2B). Surgical biopsies for some nodules were performed under general anaesthesia. The multiple lesions were yellow, wellcircumscribed and firm, located in the subcutaneous tissues, and attached to the paratenon of the extensor tendon (Fig. 3). No bacteria, fungi, or acid-fast bacilli were detected by microscopic examination and tissue culture. Histology showed
Subcutaneous granuloma annulare (SGA) is a deep dermal or subcutaneous nodule and frequently occurs in the extremities and scalp in children,1,2 but a lesion of SGA identified in the digits as aggregated multiple nodules is quite rare.3 We encountered a rare case of multiple subcutaneous nodules of SGA occurred in the digit of a young girl.
CASE REPORT An eight-year-old healthy girl presented with increasingly asymptomatic multiple nodules on her middle finger over a period of six months (Fig. 1). The patient had no local trauma history. Physical examination revealed multiple rounded elastic-hard masses on the dorsal aspect of the right middle
Correspondence to: Dr. Kazufumi Sano, Department of Orthopaedic Surgery, Dokkyo Medical University Koshigaya Hospital, 2-1-50 Minami-koshigaya Koshigaya, Saitama 343-8555, Japan. Tel: (þ81) 48-965-1111 (ext. 2626), Fax: (þ81) 48-965-4700, E-mail: [email protected] 257
May 21, 2014
10:21:16am
Hand Surg. 2014.19:257-259. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 02/01/15. For personal use only.
258
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K. Sano, K. Katagiri & S. Ozeki
Fig. 3 The multiple lesions were yellow, well-circumscribed and firm, located in the subcutaneous tissues, and attached to the paratenon of the extensor tendon. Fig. 1 Aggregatd multiple subcutaneous nodules of the dorsal aspect of the right middle finger in an eight-year-old girl.
(A)
(A)
(B)
Fig. 2 MR images of multiple masses on the dorsal aspect of the right middle finger. (A) Sagittal T1-weigted image showed masses localised to the subcutaneous tissue with homogenous lower signal intensity. (B) Sagittal fast spin-echo T2-weighted image obtained with fat saturation demonstrated that masses have high signal intensity. (B)
areas of basophilic degeneration of collagen bundles surrounded by a palisaded lymphocytic infiltrate in subcutaneous connective tissue. The pathology showed fibrovascular connective tissue containing areas of necrobiosis surrounded by a palisading histiocytic reaction (Figs. 4A and 4B). There were
Fig. 4 There were areas of collagen necrosis accompanied by palisading histiocytes. (A) Haematoxylin-eosin stain, magnification X40. (B) hematoxylineosin stain, magnification X100. (C) There were degenerated collagen fibers in the area of central necrobiosis, and increased mucin in the necrobiotic center was verified upon alcian blue staining (magnification 100).
May 21, 2014
10:21:20am
WSPC/135-HS
FA1
1472022
Atypical Subcutaneous Granuloma Annulare on the Digit
(C)
Hand Surg. 2014.19:257-259. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 02/01/15. For personal use only.
Fig. 4
259
infection, rheumatoid nodule, and necrobiosis lipoidica diabeticorum. Mucin staining with colloidal iron or alcian blue is diagnostic for SGA,1 and a complete blood count, erythrocyte sedimentation rate, haemoglobin A1c test, and the presence of rheumatoid factor, are essential to exclude rheumatoid arthritis, or diabetes mellitus. Since spontaneous resolution can be anticipated in 50% of SGA cases within two years, aggressive treatment is usually not needed. Since we hand surgeons are often the first physicians to see these lesions, we should understand SGA to avoid belated diagnosis and unnecessary radical surgery.
(Continued )
ACKNOWLEDGMENTS degenerated collagen fibers in the area of central necrobiosis, and increased mucin in the necrobiotic center was verified upon alcian blue staining (Fig. 4C). As a result of these histopathological findings, a diagnosis of SGA was determined. Remaining nodules showed a tendency toward resolution but did not completely resolve in the following eight months.
DISCUSSION SGA occurs most frequently in the anterior pretibial area in children, predominantly girls, and in 25% of cases they are associated with superficial papules.4 Involvement of hands and fingers is occasionally seen,5 but the occurrence of aggregated multiple nodules is quite rare. Although various inciting factors have been proposed, trauma appears to be the most probable aetiology in children.4 The differential diagnosis includes
We would like to thank Vern Fischer, an English language specialist at Dokkyo Medical University Koshigaya Hospital, for his assistance in editing this paper.
References 1. McNeal S, Daw JL Jr, Subcutaneous granuloma annulare. An unusual presentation in the eyelids and scalp, Ann Plast Surg 55:684–686, 2005. 2. Felner EI, Steinberg JB, Weinberg AG, Subcutaneous granuloma annulare: a review of 47 cases, Pediatrics 100:965–967, 1997. 3. Wilkes JA, Hill JJ Jr, Subcutaneous granuloma annulare of the finger, J Hand Surg 11A:429–431, 1986. 4. Letts M, Carpenter B, Soucy P, Davidson D, Subcutaneous granuloma annulare of the extremities in children, Can J Surg 43:425–430, 2000. 5. Takeyama J, Sanada T, Watanabe M, Hatori M, Kunikata N, Aiba S, Subcutaneous granuloma annulare in a child’s palm: a case report, J Hand Surg 31A:103–106, 2006.
10:21:16am
WSPC/135-HS
FA1
1472022
Hand Surgery, Vol. 19, No. 2 (2014) 257–259 © World Scientific Publishing Company DOI: 10.1142/S0218810414720228
ATYPICAL SUBCUTANEOUS GRANULOMA ANNULARE ON THE DIGIT: A CASE REPORT Kazufumi Sano,* Kazumoto Katagiri† and Satoru Ozeki* *Department
of Orthopaedic Surgery
Hand Surg. 2014.19:257-259. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 02/01/15. For personal use only.
†
Department of Dermatology Dokkyo Medical University Koshigaya Hospital Saitama 343-8555, Japan Received 31 October 2013; Revised 28 November 2013; Accepted 28 November 2013 ABSTRACT Subcutaneous granuloma annulare is a benign inflammatory disorder consisting of deep dermal or subcutaneous nodules, and frequently occurring in the extremities and scalp in children. The occurrence of aggregated multiple nodules in a digit is quite atypical. This is a report of an eight-year-old girl who presented with increasingly asymptomatic multiple nodules on her middle finger over a period of six months. Definitive diagnosis of subcutaneous granuloma annulare was achieved with surgical biopsy and no aggressive growth subsequently and showed a tendency toward spontaneous resolution. Keywords: Subcutaneous Granuloma Annulare; Subcutaneous Nodule; Tumour-like Lesion; Finger Nodule.
INTRODUCTION
finger. The surface of the mass was smooth to the touch and adhesion between the mass and its overlying skin was not identified, but mobility in relation to the underlying tissue was limited. No skin lesion was identified over the mass. Range of motion of the middle finger was not disturbed. Radiographs revealed normal findings. MR images showed that the masses were homogenous lower signal intensity on a T1-weighted image, and high signal intensity on a fast spin-echo T2weighted image obtained with fat saturation (Figs. 2A and 2B). Surgical biopsies for some nodules were performed under general anaesthesia. The multiple lesions were yellow, wellcircumscribed and firm, located in the subcutaneous tissues, and attached to the paratenon of the extensor tendon (Fig. 3). No bacteria, fungi, or acid-fast bacilli were detected by microscopic examination and tissue culture. Histology showed
Subcutaneous granuloma annulare (SGA) is a deep dermal or subcutaneous nodule and frequently occurs in the extremities and scalp in children,1,2 but a lesion of SGA identified in the digits as aggregated multiple nodules is quite rare.3 We encountered a rare case of multiple subcutaneous nodules of SGA occurred in the digit of a young girl.
CASE REPORT An eight-year-old healthy girl presented with increasingly asymptomatic multiple nodules on her middle finger over a period of six months (Fig. 1). The patient had no local trauma history. Physical examination revealed multiple rounded elastic-hard masses on the dorsal aspect of the right middle
Correspondence to: Dr. Kazufumi Sano, Department of Orthopaedic Surgery, Dokkyo Medical University Koshigaya Hospital, 2-1-50 Minami-koshigaya Koshigaya, Saitama 343-8555, Japan. Tel: (þ81) 48-965-1111 (ext. 2626), Fax: (þ81) 48-965-4700, E-mail: [email protected] 257
May 21, 2014
10:21:16am
Hand Surg. 2014.19:257-259. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 02/01/15. For personal use only.
258
WSPC/135-HS
FA1
1472022
K. Sano, K. Katagiri & S. Ozeki
Fig. 3 The multiple lesions were yellow, well-circumscribed and firm, located in the subcutaneous tissues, and attached to the paratenon of the extensor tendon. Fig. 1 Aggregatd multiple subcutaneous nodules of the dorsal aspect of the right middle finger in an eight-year-old girl.
(A)
(A)
(B)
Fig. 2 MR images of multiple masses on the dorsal aspect of the right middle finger. (A) Sagittal T1-weigted image showed masses localised to the subcutaneous tissue with homogenous lower signal intensity. (B) Sagittal fast spin-echo T2-weighted image obtained with fat saturation demonstrated that masses have high signal intensity. (B)
areas of basophilic degeneration of collagen bundles surrounded by a palisaded lymphocytic infiltrate in subcutaneous connective tissue. The pathology showed fibrovascular connective tissue containing areas of necrobiosis surrounded by a palisading histiocytic reaction (Figs. 4A and 4B). There were
Fig. 4 There were areas of collagen necrosis accompanied by palisading histiocytes. (A) Haematoxylin-eosin stain, magnification X40. (B) hematoxylineosin stain, magnification X100. (C) There were degenerated collagen fibers in the area of central necrobiosis, and increased mucin in the necrobiotic center was verified upon alcian blue staining (magnification 100).
May 21, 2014
10:21:20am
WSPC/135-HS
FA1
1472022
Atypical Subcutaneous Granuloma Annulare on the Digit
(C)
Hand Surg. 2014.19:257-259. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 02/01/15. For personal use only.
Fig. 4
259
infection, rheumatoid nodule, and necrobiosis lipoidica diabeticorum. Mucin staining with colloidal iron or alcian blue is diagnostic for SGA,1 and a complete blood count, erythrocyte sedimentation rate, haemoglobin A1c test, and the presence of rheumatoid factor, are essential to exclude rheumatoid arthritis, or diabetes mellitus. Since spontaneous resolution can be anticipated in 50% of SGA cases within two years, aggressive treatment is usually not needed. Since we hand surgeons are often the first physicians to see these lesions, we should understand SGA to avoid belated diagnosis and unnecessary radical surgery.
(Continued )
ACKNOWLEDGMENTS degenerated collagen fibers in the area of central necrobiosis, and increased mucin in the necrobiotic center was verified upon alcian blue staining (Fig. 4C). As a result of these histopathological findings, a diagnosis of SGA was determined. Remaining nodules showed a tendency toward resolution but did not completely resolve in the following eight months.
DISCUSSION SGA occurs most frequently in the anterior pretibial area in children, predominantly girls, and in 25% of cases they are associated with superficial papules.4 Involvement of hands and fingers is occasionally seen,5 but the occurrence of aggregated multiple nodules is quite rare. Although various inciting factors have been proposed, trauma appears to be the most probable aetiology in children.4 The differential diagnosis includes
We would like to thank Vern Fischer, an English language specialist at Dokkyo Medical University Koshigaya Hospital, for his assistance in editing this paper.
References 1. McNeal S, Daw JL Jr, Subcutaneous granuloma annulare. An unusual presentation in the eyelids and scalp, Ann Plast Surg 55:684–686, 2005. 2. Felner EI, Steinberg JB, Weinberg AG, Subcutaneous granuloma annulare: a review of 47 cases, Pediatrics 100:965–967, 1997. 3. Wilkes JA, Hill JJ Jr, Subcutaneous granuloma annulare of the finger, J Hand Surg 11A:429–431, 1986. 4. Letts M, Carpenter B, Soucy P, Davidson D, Subcutaneous granuloma annulare of the extremities in children, Can J Surg 43:425–430, 2000. 5. Takeyama J, Sanada T, Watanabe M, Hatori M, Kunikata N, Aiba S, Subcutaneous granuloma annulare in a child’s palm: a case report, J Hand Surg 31A:103–106, 2006.
