Ann Dermatol.  2018 Dec;30(6):716-720. 10.5021/ad.2018.30.6.716.

Perforating Granuloma Annulare Mimicking Papulonecrotic Tuberculid

• Chae MH
• Shin JY
• Lee JY
• Yoon TY

• KMID: 2428930
• DOI: http://doi.org/10.5021/ad.2018.30.6.716

Abstract

Perforating granuloma annulare (PGA), a rare variant of granuloma annulare, is characterized by transepidermal elimination of altered collagen that clinically manifests an umbilicated papule with a central crust. It can be confused with papulonecrotic tuberculid (PNT) because of their similar appearance. Unlike PGA, PNT is usually related to tuberculosis infection with a typical histologic finding of wedge-shaped dermal necrosis. Here, we report the first Korean case of PGA mimicking PNT both clinically and histologically. A 43-year-old Korean woman presented with erythematous papules localized on the extensor surface of her limbs for one year. Some of these papules had a central umbilication or a crust. Regarding comorbidity, she had latent tuberculosis diagnosed with QuantiFERON®-TB Gold test about five months ago. She was on antituberculous medication. Initially, a diagnosis of papulonecrotic tuberculid accompanied by latent tuberculosis was considered. However, despite taking the antituberculous medication for five months, her skin lesions were not improved. Biopsy specimen from her arm lesion showed wedge-shaped area of necrosis in the dermis. Additionally, there were multiple focal mucin depositions and palisading granulomatous inflammation throughout the dermis. A diagnosis of PGA was made and she was treated with topical corticosteroid. After two weeks of applying topical corticosteroid, most of her skin lesions disappeared, leaving some hyperpigmented scars.

Keyword

Papulonecrotic tuberculid; Perforating granuloma annulare

MeSH Terms

Adult
Arm
Biopsy
Cicatrix
Collagen
Comorbidity
Dermis
Diagnosis
Extremities
Female
Granuloma Annulare*
Granuloma*
Humans
Inflammation
Latent Tuberculosis
Mucins
Necrosis
Skin
Tuberculosis
Tuberculosis, Cutaneous*
Collagen
Mucins

Figure

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  Fig. 1 About 3~5 mm sized, numerous erythematous to brownish colored papules on the extensor surface of limbs. Closer view of the papule shows an umbilication (arrow) and a central crust (empty arrow). We received the patient's consent form about publishing all photographic materials.

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  Fig. 2 (A) Wedge-shaped area of necrosis in the upper dermis surrounded by perivascular lymphohistiocytic infiltration (H&E, ×40). (B) The necrotic area is consisted of altered collagen fibers (Masson's trichrome staining, ×40). (C, D) Focal mucin deposition surrounded by palisades of histiocytes near the wedge-shaped dermal necrosis (C: H&E, ×100, D: Alcian blue at pH 2.5, ×100).

• 

  Fig. 3 (A, B) Increased mucin coupled with collection of histiocytes intercalated between collagen bundles in the lower dermis (A: H&E, ×100, B: Alcian blue at pH 2.5, ×100).

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