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CASE REPORT
Year : 2006  |  Volume : 51  |  Issue : 2  |  Page : 134-136
Pyogenic granuloma with multiple and satellite lesions


1 Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi - 110 029, India
2 Department of Pathology, All India Institute of Medical Sciences, New Delhi - 110 029, India

Correspondence Address:
Binod K Khaitan
Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.26938

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   Abstract 

Pyogenic granuloma is a benign vascular tumour of the skin or mucosa. We report two patients of pyogenic granuloma with spontaneous occurrence of multiple and satellite lesions, a rare occurrence.


Keywords: Pyogenic granuloma, Satellite lesions, Multiple


How to cite this article:
Sethuraman G, Khaitan BK, Sirka CS, Prasad H, Agarwal S, Singh MK, Sharma VK. Pyogenic granuloma with multiple and satellite lesions. Indian J Dermatol 2006;51:134-6

How to cite this URL:
Sethuraman G, Khaitan BK, Sirka CS, Prasad H, Agarwal S, Singh MK, Sharma VK. Pyogenic granuloma with multiple and satellite lesions. Indian J Dermatol [serial online] 2006 [cited 2019 Nov 13];51:134-6. Available from: http://www.e-ijd.org/text.asp?2006/51/2/134/26938



   Introduction Top


Pyogenic granuloma is a cutaneous vascular proliferation affecting the skin or mucosa. It usually presents as a solitary ulcerated papule or plaque. Multiplicity or satellitosis is uncommon, but may develop following treatment or trauma. We describe two patients of pyogenic granuloma with spontaneous occurrence of multiple and satellite lesions and the result of one of them treated with shave excision and electrocauterization.


   Case Reports Top


Patient 1

A 22-year-old woman developed a few papular lesions on the left temporal region of the scalp. The lesions progressed as well as new lesions appeared slowly to form 15 to 20 lesions in the next four years. She gave history of recurrent scanty frank bleeding or serosanguinous discharge especially while combing her hair. There was no history of pain or itching. She did not have any other cutaneous or systemic symptoms. There was no history of spontaneous resolution or previous treatment. At the time of presentation she had multiple skin colored to erythematous soft to firm papules and nodules over the left frontal and temporal region of the scalp, ranging from 5-15 mm in size. Some lesions had dark-brown crusts on it and the surface of most of the lesions had an irregular verrucous look. In addition there were few tiny but similar satellite papules seen at the periphery [Figure - 1]. Histopathological examination of a papular lesion showed proliferation of numerous thin walled blood vessels (lined by single layer of endothelial cells, containing red blood cells). These were located in the loose stroma in the papillary dermis lacking collagen. There was also proliferation of endothelial cells, (which were plump), along with fibroblasts. Warthin-Starry stain was done to rule out bacillary angiomatosis and it did not show any organism. The epidermis was thin and there was no breach [Figure - 2]. The surgical shave excision of the lesions followed by electrocautery of the base was done in three sittings at 2 weekly intervals and the lesions were completely cleared. At the end of 3 months, her scalp was healthy and had almost complete regrowth of hair with minimal scarring [Figure - 3]. There was no recurrence in the total follow up period of 9 months.

Patient 2

A 55-year-old man presented with appearance of multiple erythematous papular and nodular lesions on the left cheek since 2 months. Initially, he developed a single erythematous papule, which gradually increased in size with appearance of new lesions in the near vicinity of the initial lesion. After a month there had been a rapid increase in the number of lesions, scattered slightly away from the primary lesion. He did not recall any obvious trauma to the area prior to the development of the lesions, however he complained of bleeding during shaving. On examination, he had closely grouped dark red smooth surfaced papules and nodules of size 0.5-1.5 cm on the left cheek. He also had scattered dark red, dome shaped 3-5 mm satellite papules around the primary lesions [Figure - 4]. Some of the lesions had dark red hemorrhagic crusts. The lesions were non tender and did not bleed on palpation. Histopathological examination of a papular lesion confirmed the diagnosis of pyogenic granuloma. Warthin-Starry stain of the section did not reveal any organism. The patient was referred for treatment with pulse dye laser.


   Discussion Top


Pyogenic granuloma otherwise known as acquired lobular capillary hemangioma is a solitary benign vascular tumour of the skin or mucosa.[1] It most often affects the children and young adults, sometimes pregnant women and rarely elderly individuals.[1],[2] The color of the lesion is bright red to brownish red or blue black.[2] The surface of an early lesion is thin and intact but the older lesions often show ulceration and crusting and it bleeds easily on manipulation. Rarely the surface is raspberry like or even verrucous. The size varies between 5 and 10 mm sometimes it may reach upto 50 mm.[2] The commonest site affected are the face, especially the lip, and extremities, mainly the fingers.[3] The other sites of involvement are the upper trunk, head and rarely oral mucosa and perianal area.[2] Usually, pyogenic granuloma presents as a solitary lesion. The multiplicity of satellite lesions is uncommon and if multiple lesions appear, they develop around the site of recently treated lesions, more as a phenomenon of recurrence. They may develop after excision, shave excision, elecrodesiccation, ligation, curettage and cautery.[3],[4] Occurrence of multiple lesions following CO 2 laser has been reported.[3] Deroo et al have described the development of multiple satellite pyogenic granuloma after removal of a melanocytic nevus.[5] It can occur within the primary scar or just beneath it.[6] Recurring lesions which are nearest to the scar are generally larger and more numerous. In a majority of the patients with satellite lesions, the site involved is the trunk, especially around the scapula either with or without recurrence of the primary lesion. They tend to be asymptomatic and may resolve spontaneously within 6-12 months.[3] The interesting feature which characterized both our patients is the spontaneous occurrence of multiple and satellite lesions, which has rarely been reported.[7] It is possible that frequent trauma because of combing of hair in the first case and shaving in the second case would have caused irritation of the primary lesions and triggered the development of satellitosis. In the first case, though the lesions were confined to temporal and frontal areas of scalp the size of the lesions were large (10-15 mm). The second case had a ring of smaller satellite lesions around a central large lesion.

The exact pathogenesis of multiple and satellite pyogenic granuloma whether it occurs following treatment or de novo , is not clearly understood. But various theories have been proposed. Trauma can cause release of various endogenous substances including angiogenic factors from the tumor cells and it may also cause disturbances in the vascular system of the affected area. Itin et al[1] in their case of pyogenic granuloma, identified clumps of dark bacilli in the skin biopsy specimen stained with Warthin-Starry technique, as seen in patients with bacillary angiomatosis. They also observed IgG antibodies against Bartonella (Rachalimaea) henselae and suggested that pyogenic granuloma could be a localized variant of bacillary angiomatosis.[1] However, the primary trigger for development of pyogenic granuloma is believed to be trauma.

 
   References Top

1.Itin PH, Fluckiger R, Zbinden R, Frei R. Recurrent pyogenic granuloma with satellitosis. A localized variant of bacillary angiomatosis? Dermatology 1994;189:409-2.   Back to cited text no. 1    
2.Mackie RM. Soft tissue tumors In : Champion RH, Burton JL, Burns DA, Breathnach SM, editors. Textbook of Dermatology. Blackwell Science: Oxford; 1998. p. 2354-5.   Back to cited text no. 2    
3.Blickenstaff RD, Roenigk RK, Peters MS, Goellner JR. Recurrent pyogenic granuloma with satellitosis. J Am Acad Dermatol 1989;21:1241-4.   Back to cited text no. 3  [PUBMED]  
4.Shah M, Kingston TP, Cotterill JA. Eruptive pyogenic granuloma:a successfully treated patient and review of literature. Br J Dermatol 1995;133:795-6.  Back to cited text no. 4  [PUBMED]  
5.Deroo M, Eeckhout I, Naeyaert JM. Eruptive satellite vascular malformation after removal of a melanocytic nevus. Br J Dermatol 1997;137:292-5.   Back to cited text no. 5  [PUBMED]  
6.Warner J, Jones EW. Pyogenic granuloma recurring with multiple satellitosis. A report of 11 cases. Br J Dermatol 1968;80:218-27.   Back to cited text no. 6  [PUBMED]  
7.Taria JW, Hill TL, Everett MA. Lobular capillary hemangioma (pyogenic granuloma) with satellitosis. J Am Acad Dermatol 1992;27:297-300.  Back to cited text no. 7    


    Figures

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

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