Year : 2006 | Volume
: 51 | Issue : 3 | Page : 217--220
Infectious granulomatous dermatitis: A clinico pathological study
Amanjit Bal1, Harsh Mohan1, GP Dhami2,
1 Department of Pathology, Govt. Medical College and Hospital, Sector 32-A, Chandigarh - 160 030, India
2 Department of Dermatology, Govt. Medical College and Hospital, Sector 32-A, Chandigarh - 160 030, India
Department of Pathology, Govt. Medical College and Hospital, Sector 32-A, Chandigarh - 160 030
Granulomatous dermatitis frequently presents a diagnostic challenge to dermatopathologists as an identical histologic picture is produced by several causes. Present study aims at classifying infectious granulomatous dermatitis based on etiology and morphology of granulomas, and to highlight significance of clinical correlation in making a specific diagnosis. A retrospective analysis of skin biopsies was done and cases of infectious granulomatous dermatitis diagnosed on histopathological examination were retrieved. A total of 586 cases of granulomatous dermatitis were retrieved; out of these, on the basis of clinico-pathological findings, 515 cases (87.8%) were categorized as infectious granulomatous dermatitis. The age of the patients ranged from 7-80 years with a male to female ratio of 1.5:1. Majority of the cases were of leprosy (373 cases, 72.4%) which were further classified into sub-groups according to Ridley and Jopling. Second largest group was of cutaneous tuberculosis including tuberculids (119 cases, 23.1%). Fungal dermatitis was diagnosed in 17 cases (3.3%) and 6 cases (1.16%) were diagnosed as post kala-azar dermal leishmaniaisis based on the lympho-histiocytic and plasma cell inflitrate. Infections form an important cause of granulomatous dermatitis with leprosy and tuberculosis as the leading causes. Adequate clinical data and workup in combination with pathological resources can help in elucidation of specific etiology and good clinicopathologic correlation.
|How to cite this article:|
Bal A, Mohan H, Dhami G P. Infectious granulomatous dermatitis: A clinico pathological study.Indian J Dermatol 2006;51:217-220
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Bal A, Mohan H, Dhami G P. Infectious granulomatous dermatitis: A clinico pathological study. Indian J Dermatol [serial online] 2006 [cited 2021 Jan 28 ];51:217-220
Available from: https://www.e-ijd.org/text.asp?2006/51/3/217/27993
Granulomatous dermatitis is a pattern of reaction to various organic and inorganic antigens. According to the current concept, 'granuloma' is defined as 'a focal chronic inflammatory response to tissue injury characterized by collection of activated histiocytes, epithelioid cells and multinucleate giant cells that may or may not be rimmed by lymphocytes and/or show central necrosis'.
Granulomatous dermatitis frequently poses a diagnostic challenge to dermatopathologists, since an identical histologic picture is produced by several causes, and, conversely, a single cause may produce varied histologic patterns., Moreover it is difficult to present a completely satisfactory classification of granulomatous dermatitis. Present study aims at classifying infectious granulomatous dermatitis based on etiology and morphology of granulomas, and to highlight significance of clinical correlation in making a specific diagnosis.
Materials and Methods
A retrospective analysis of skin biopsies received in the Department of Pathology, Government Medical College, Chandigarh over a period of 7 years was done and cases of infectious granulomatous dermatitis diagnosed on histopathological examination were retrieved.
Clinical informations like appearance and duration of lesion and clinical diagnosis were recorded. In each case, haematoxylin and eosin stained paraffin sections along with special stains like PAS, Gomori's Methenamine lepra, Ziehl Neelsen (ZN), Giemsa, reticulin etc. were studied.
A total of 586 cases of granulomatous dermatitis were retrieved. Out of these, on the basis of clinico-pathological findings, 515 cases (87.8%) were categorized as infectious granulomatous dermatitis. The age of the patients ranged from 7-80 years with a male to female ratio of 1.5:1. Cases included in infectious granulomatous dermatitis are presented in [Table 1].
Majority of the cases were of leprosy (373 cases, 72.4%). This group was classified into sub-groups according to Ridley and Jopling. Biopsies with well-formed epithelioid granulomas with rim of lymphocytes distributed throughout the dermis, especially around adnexal structures and neurovascular bundles and encroaching upon basal layer of epidermis, were classified as tuberculoid leprosy (TT; 27 cases, 7.2%); cases with granulomas having fewer lymphocytes and more number of foreign body giant cells and not encroaching upon epidermis were classified as borderline tuberculoid leprosy (BT; 206 cases, 55.2%, [Figure 1]); cases having granulomas rich in foamy histiocytes and few epithelioid cells were grouped into borderline lepromatous leprosy (BL; 56 cases, 15%); and cases with diffuse sheets of foamy histiocytes with Grenz zone were classified as lepromatous leprosy (LL; 67 cases, 17.9%, [Figure 2]). In addition, cases with type I and type II reaction were also seen (erythema nodosum leprosum i.e., ENL 8 cases, 2.1%, and downgrading/upgrading reaction 9 cases, 2.4%). Lepra stain was positive in 136 cases (36.4%): 123 cases of BL and LL, 7 cases of BT, and 6 cases of ENL.
The second largest group was of cutaneous tuberculosis including tuberculids (119 cases, 23.1%). This group was further classified as lupus vulgaris (60 cases, 50.4%, [Figure 3]) having well formed epithelioid cell granulomas with or without caseation necrosis in the dermis, scrofuloderma (46 cases, 38.6%) showing surface ulceration and admixture of neutrophilic abscesses and tuberculosis verrucosa cutis (3 cases, 2.5%) with marked epidermal hyperplasia and neutrophilic abscesses in the epidermis. Tuberculids were classified as lichen scrofulosorum (6 cases, 5%) with perifollicular inflammatory reaction admixed with granulomas; papulonecrotic tuberculid (3 cases, 2.5%) showing vasculitis and coagulative necrosis in dermis; and, erythema induratum (1 cases, 0.8%) having granulomatous panniculitis. Ziehl Neelsen (ZN) stain for acid fast bacilli was positive in 6 cases (5%) only (3 cases (5%) of lupus vulgaris and 3 cases (6.5%) of scrofuloderma).
Fungal dermatitis was diagnosed in 17 cases (3.3%). They were categorized as sporotrichosis (6 cases, [Figure 4]), mycetoma (4 cases), tinea (3 cases), protothecosis (2 cases) and one case each of chromoblastomycosis and mucor. Six cases (1.16%) were diagnosed as post kala-a-zar dermal leishmaniaisis based on the lympho-histiocytic and plasma cell inflitrate. LD bodies were identified in 3 (50%) cases [Figure 5] only.
Granulomatous inflammation is a chronic inflammatory process in response to an antigen. There is considerable variation in the microscopic appearance of granulomas producing different morphologic pictures within the same biopsy or from one lesion to another.
It is difficult to present a completely satisfactory classification of granulomatous dermatitis. It has been previously classified on the basis of pathophysiology, etiology, immunology, and morphology. In the present study, granulomatous dermatitis was classified using a combination of etiology and morphology of granuloma.
Infectious granulomatous dermatitis was subclassified on the clinical impression, location of granuloma, morphology of granuloma and identification of infectious agent with the help of special stains. Majority of the cases (72.4%) were of leprosy and of these borderline tuberculoid formed the largest subgroup of Ridley and Jopling (55.2%). Granulomas of tuberculoid (TT) and borderline tuberculoid (BT) leprosy are epithelioid granulomas with Langhans' and foreign body giant cells and thus requires differentiation from sarcoidosis and non-caseating tuberculous granulomas., In such cases lepra stain is not of much help because of sparse bacilli. In the present study, only 6 cases of BT and none of TT were positive for lepra bacilli. However, location of granulomas around neurovascular bundle, erector pili muscle and adenexa in combination with clinical picture are helpful. Borderline lepromatous (BL) and lepromatous leprosy (LL) are characterised by histiocytic granulomas and are strongly positive for lepra bacilli, thus posing no difficulty in diagnosis. Clinically lesions of post kala-a-zar dermal leishmaniasis (PKDL) may mimic those of LL causing diagnostic confusion. Histopathological examination for type of infiltrate and Giemsa stain for LD bodies can resolve the problem. It is usually difficult to detect LD bodies in paraffin sections, but plasma cell-histiocytic inflitrate can suggest the diagnosis. In the present study LD bodies were identified in 50% cases only.
The next frequently encountered lesion was of cutaneous tuberculosis. Different clinical patterns like lupus vulgaris, scrofuloderma and tuberculosis verrucosa cutis represent reinfection and reactivation of tuberculosis. Caseation necrosis in an epithelioid granuloma is diagnostic, but its absence does not rule out diagnosis of tuberculosis. Demonstration of acid fast bacilli by ZN stain is specific; however, they are not detected with ease and literature has reported 13-15% positivity in lupus vulgaris (5% in present study) and upto 50% positivity in scrofuloderma (6.5% in present study)., Tuberculids represent the hypersensitivity reaction to tubercular antigen and cannot be diagnosed on morphology alone. They are diagnosed if associated tuberculous infection is present elsewhere in the body. Lupus miliaris disseminatum faciei morphologically resembles cutaneous tuberculosis because of extensive areas of caseation necrosis, thus requires clinical correlation for diagnosis.
Fungal infections are characterised by mixed/suppurative granulomas. Demonstration of fungal spores/hyphae or asteroid body with central spore with the help of special stains like PAS and Gomori's methenamine is confirmatory. In the present study fungal spores were identified in all but 3 cases of sporotrichosis. In these cases type of infiltrate was suggestive and diagnosis was later confirmed by culture.
Infections form an important cause of granulomatous dermatitis with leprosy and tuberculosis as the leading etiology. There is a significant overlap in histopathologic picture of different granulomatous reactions. Thus, morphology alone is seldom specific and cannot be used as diagnostic tool for identification of specific diseases. Adequate clinical data and workup in combination with pathological resources can help in elucidation of specific etiology and good clinico-pathologic correlation.
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