Indian Journal of Dermatology
  Publication of IADVL, WB
  Official organ of AADV
Indexed with Science Citation Index (E) , Web of Science and PubMed
 
Users online: 123  
Home About  Editorial Board  Current Issue Archives Online Early Coming Soon Guidelines Subscriptions  e-Alerts    Login  
    Small font sizeDefault font sizeIncrease font size Print this page Email this page


 
Table of Contents 
E-IJD CORRESPONDENCE
Year : 2016  |  Volume : 61  |  Issue : 1  |  Page : 124
A rare report of granuloma multiforme


1 Department of Dermatology, Dr. D. Y. Patil Medical College and Hospital, Pune, Maharashtra, India
2 Department of Pathology, Dr. D. Y. Patil Medical College and Hospital, Pune, Maharashtra, India

Date of Web Publication15-Jan-2016

Correspondence Address:
Garima Malik
Department of Dermatology, Dr. D. Y. Patil Medical College and Hospital, Pune, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.174168

Rights and Permissions



How to cite this article:
Sharma YK, Ankadavar NS, Malik G, Patel RJ. A rare report of granuloma multiforme. Indian J Dermatol 2016;61:124

How to cite this URL:
Sharma YK, Ankadavar NS, Malik G, Patel RJ. A rare report of granuloma multiforme. Indian J Dermatol [serial online] 2016 [cited 2019 Sep 22];61:124. Available from: http://www.e-ijd.org/text.asp?2016/61/1/124/174168


Sir,

The term granuloma multiforme was coined in 1964 by Leiker et al., to describe a reactive skin disorder of unknown etiology "resembling leprosy" with "the variety of clinical presentation and the granulomatous histology." [1] Characterized clinically by confluent annular lesions and histopathologically by focal necrobiosis and histiocytic granulomas, most of its cases have been found mistakenly receiving treatment for leprosy in leprosy settlements from the African continent. [2] Our present report is probably, the fifth from India [2],[3],[4],[5] and the first from Maharashtra.

A 59-year-old housewife presented with numerous annular plaques over forearms, which commenced as itchy papules 3 years back and gradually extended to involve upper back. There were neither any seasonal and diurnal variations nor any aggravating or relieving factors. Denied history of contact with known patients of leprosy. Her body mass index was 33. Dermatological examination revealed numerous erythematous, clustered papules symmetrically over hands, forearms [Figure 1], upper back forming well-defined, and polycyclic plaques with central clearing without any sensory loss or peripheral nerve thickening. Biopsy from the edge of a lesion on left forearm revealed mid-dermal lymphohistiocytic infiltrate with many multinucleated giant cells surrounding foci of necrobiotic collagen [Figure 2], and perivascular lymphocytic infiltrate [Figure 3]. The colloidal iron stain did not reveal increased mucin deposition, which ruled out granuloma annulare. Ziehl-Neelsen stain did not reveal acid-fast Bacilli. These classical clinical and histopathological findings corroborated the diagnosis of granuloma multiforme. Complete hemogram, urinalysis, kidney and liver function tests, blood glucose levels, and T3, T4, thyroid stimulating hormone were normal. A trial of topical corticosteroids failed to show any improvement.
Figure 1: Polycyclic plaques with central clearing over ventral aspect of forearm

Click here to view
Figure 2: Dermis showing necrobiotic granuloma (H and E, ×100)

Click here to view
Figure 3: Dermis showing prominent multinucleated giant cells with perivascular lymphohistiocytic infiltrate (H and E, ×400)

Click here to view


Cumulative photodamage to the dermal collagen has been favored as the primary pathogenetic event of granuloma multiforme, whose lesions in almost all cases have been confined to sun-exposed sites. [2] Some believe, this disorder to be granuloma annulare on light-exposed areas because of relatively similar clinical and histological features. Adults over 40 years, more so females, are commonly affected. [3] Pruritus and irritation are especially associated with the onset of small papules of granuloma multiforme; these papules aggregate to form annular and polycyclic patterns extending peripherally with central clearing, usually with residual hypopigmentation and occasionally hyperpigmentation. Response to the treatment is poor.

Granuloma annulare, actinic granuloma, sarcoidosis, and necrobiosis lipoidica diabeticorum also need to be considered in the differential diagnosis of granuloma multiforme in addition to the usual mimic of tuberculoid leprosy; [2] the latter having sensory impairment, nerve trunk thickening but lacking degenerated collagen. [4] Granuloma annulare presents with asymptomatic lesions in younger age group and reveals increased mucin deposition surrounded by granulomatous zone histopathologically with scarce giant cells with fewer nuclei. [2] The yellowish color of the plaques, telangiectasia, the involvement of the lower limbs, and the presence of fibrosis intermingled with necrosis, vessel wall changes and fat deposition in deep reticular dermis characterize the necrobiosis lipoidica. [4]

Extremely few reports of granuloma multiforme from India, despite foci of endemic leprosy, indicate possible misdiagnosis and emphasizes the need for heightening index of suspicion for this condition in the differential diagnosis of annular granulomatous disorders. Corroboration by lesional histopathological examination usually suffices to clinch the diagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Leiker DL, Kok SH, Spaas JAJ. Granuloma multiforme: A new disease resembling leprosy. Int J Lepr 1964;32:368-76.  Back to cited text no. 1
    
2.
Kumari R, Thappa DM, Chougule A, Adityan B. Granuloma multiforme: A report from India. Indian J Dermatol Venereol Leprol 2009;75:296-9.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Mukhopadhyay AK. Granuloma multiforme. Indian J Dermatol 2004;49:202-3.  Back to cited text no. 3
  Medknow Journal  
4.
Cherian S. Granuloma multiforme in India. Int J Lepr Other Mycobact Dis 1990;58:719-21.  Back to cited text no. 4
    
5.
Sandhu K, Saraswat A, Gupta S, Shukla R, Handa S. Granuloma 2 multiforme. Int J Dermatol 2004;43:441-3.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
Print this article  Email this article
 
 
  Search
 
  
    Similar in PUBMED
    Article in PDF (1,414 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    References
    Article Figures

 Article Access Statistics
    Viewed992    
    Printed8    
    Emailed0    
    PDF Downloaded50    
    Comments [Add]    

Recommend this journal