Case Reports Infarcted Tarsal Pyogenic Granuloma Simulating Malignant Melanoma Norman C. Charles, M.D.*† and Jonathan B. Kahn, M.D.* Abstract: The authors describe a rapidly enlarging, pedunculated brown tarsal lesion in a 34-year-old man with a history of chalazia. Following excision, histopathologic analysis showed the features of a necrotic pyogenic granuloma. This unique case expands the differential diagnosis of conjunctival malignant melanoma.


yogenic granulomas represent exuberant granulation tissue occurring in areas of defective re-epithelialization of injured tissue. Their inherent vascularity produces a reddish or pink clinical hue, although tan coloration may result from intralesional fibrosis. The authors report a rare case of infarcted pyogenic granuloma, the chocolate color of which suggested a melanoma. This study was conducted in compliance with the rules and regulations of the Health Insurance Portability and Accountability Act.

FIG. 1.  Pedunculated pigmented tumor attached to tarsal conjunctiva of left lower eyelid.

REPORT OF A CASE A healthy 34-year-old Caucasian man presented with a 10-day history of an enlarging brown mass of the left lower eyelid, along with mild discharge, bloody tears, edema, and erythema. Multiple recurrent chalazia of the eyelid had been excised about 15 years previously. Examination showed a pedunculated, dark brown, 8 × 6 mm mobile lesion emanating from the tarsal conjunctiva (Fig. 1). Uncorrected visual acuity was 20/20 OU and there were no other ocular abnormalities. After a week of topical steroid drops, there was only slight shrinkage of the lesion and excision was performed. Histopathologic examination showed an unusual vascular pattern of numerous blood-filled, capillary-sized channels that mostly lacked endothelium and were surrounded by collars of fibrinoid necrosis. Scant numbers of neutrophils and lymphocytes were present in the interstitium. CD34 and CD31 immunostains highlighted the vascular network (Fig. 2). Rare foci of hemosiderin were detected at the surface of the lesion by the iron stain. HHV8 immunostain was negative, militating against Kaposi’s sarcoma.

DISCUSSION Pyogenic granuloma usually denotes a sequel of incomplete surgical or traumatic wound healing wherein exuberant granulation tissue (capillaries, acute, and chronic inflammatory cells) insinuates itself between the unopposed wound margins. In a series of 100 pyogenic granulomas, a primary predisposing factor (42%) was the defective epithelialization of an underlying chalazion.1 Most lesions are pedunculated. The pattern of an infarcted pyogenic granuloma in the current case most likely resulted from the lesion twisting on its pedicle with attendant loss of blood supply.

Accepted for publication May 22, 2015. *Department of Ophthalmology, and †Department of Pathology, New York University Langone Medical Center, New York, New York, U.S.A. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Norman C. Charles, M.D., NYU Langone Medical Center, 550 First Avenue, New York, NY 10016. E-mail:[email protected] DOI: 10.1097/IOP.0000000000000525

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FIG. 2.  A, Histology shows erythrocytes within capillary channels mostly devoid of endothelium amidst basophilic stromal necrosis (asterisk). Rare endothelial cells remain (arrowhead) with occasional necrotic epithelium (arrow; hematoxylin-eosin, original magnification, ×300). Inset Collars of fibrinoid necrosis surrounding capillaries. (hematoxylineosin, original magnification, ×300). B, CD31 immunostain highlights vascular pattern (immunoperoxidase reaction, diaminobenzidine chromogen, original magnification ×100).

Pyogenic granuloma has a separate incarnation in the dermatology literature as a primary vascular neoplasm often


Copyright © 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.

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Case Reports

termed “lobular capillary hemangioma.”2 The current case, showing a pedunculated lesion overlying a zone of pre-existing chalazia, departs from the usual reddish/purple coloration due to the brown/black hue inherent in tissue necrosis. Although viable erythrocytes were present in the lesion, the additional necrotic components blocked the reflection of red light from the tumor (Tyndall effect). Therapy of pyogenic granuloma is primarily surgical excision. While topical steroids may cause shrinkage of the lesion, they will not completely eliminate its vascular and fibrotic components. Following transection of the peduncle in tarsal lesions, exploration for underlying chalazia is advisable. Excision of epibulbar or cutaneous lesions should include careful approximation and suturing of wound edges to prevent recurrence. Sole pigmented lesions of the tarsal conjunctiva, less common than epibulbar lesions, are usually flat and include primary and metastatic malignant melanoma, unusual nevi (blue and combined),3 secondarily pigmented epithelial tumors,4 oxidized epinephrine eye drops, ochronosis,5 kohl cosmetics,6 and melanosis oculi. Combinations of pigmented lesions involving both tarsal and bulbar conjunctiva may occur as in primary acquired melanosis.7 Concern for melanoma in the current case was low, being based upon its dark pigmentation rather than


pedunculation or rapid time course. Still—although rare—an acquired flat or enlarging tarsal pigmented growth, warrants biopsy to rule out malignant melanoma.

REFERENCES 1. Ferry AP. Pyogenic granulomas of the eye and ocular adnexa: a study of 100 cases. Trans Am Ophthalmol Soc 1989;87:327–43; discussion 343–7. 2. Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): a clinicopathologic study of 178 cases. Pediatr Dermatol 1991;8:267–76. 3. Jakobiec FA, Stacy RC, Thakker MM. Blue nevus of the tarsus as the predominant component of a combined nevus of the eyelid. Ophthal Plast Reconstr Surg 2011;27:e94–6. 4. Jauregui HO, Klintworth GK. Pigmented squamous cell carcinoma of cornea and conjunctiva: a light microscopic, histochemical, and ultrastructural study. Cancer 1976;38:778–88. 5. Urbánek T, Rovensky J. Manifestations of alkaptonuric ochronosis in the eye. In: Rovensky A, Urbánek T, Baldiŝová O, Gallagher J, eds. Alkaponuria and Ochronosis. New York, NY: Springer, 2015:79–86. 6. Hidayat A. Conjunctival and lacrimal sac pigmentation by kohl (eyeliner). Br J Ophthalmol 1997;81:415. 7. Shields CL, Shields JA, Gündüz K, et al. Conjunctival melanoma: risk factors for recurrence, exenteration, metastasis, and death in 150 consecutive patients. Arch Ophthalmol 2000;118:1497–507.

© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.

Copyright © 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.

Infarcted Tarsal Pyogenic Granuloma Simulating Malignant Melanoma.

The authors describe a rapidly enlarging, pedunculated brown tarsal lesion in a 34-year-old man with a history of chalazia. Following excision, histop...
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