Description
A woman in her late 60s presented to the dermatology clinic with a problem of asymptomatic skin-coloured raised lesions over her upper limbs, back of the trunk and abdomen for the past year. She initially noticed lesions over her right forearm, then, over the next 4 months, similar lesions appeared over the back of the trunk and sides of the abdomen. She had no surgical or rheumatological history.
Cutaneous examination showed multiple annular skin-coloured papules and varying-sized plaques with central clear zones and raised borders. In some places, papules were seen coalescing to form plaques distributed predominantly over the back of the trunk and flexor aspects of both arms and sides of the abdomen (figures 1 and 2). Complete haemogram, plasma lipid panel and serum biochemistry for liver and renal function tests were within the normal limits. Serology for viral infections (hepatitis B, hepatitis C and HIV) were negative. Her random blood sugar and glycosylated haemoglobin were 155 mg/dL and 6.6%, respectively.
Figure 1.
Multiple annular skin-coloured papules and plaques of varying sizes over the back of the trunk.
Figure 2.
Multiple skin-coloured annular papules and plaques over the sides of the abdomen.
A 4 mm punch biopsy from one of the lesions showed necrobiotic palisading granulomas with occasional multinucleated giant cells. The palisading granulomas were centred around a blue degraded collagen surrounded by lymphocytes and histiocytes (figure 3)
Figure 3.
H&E-stained section of skin biopsy showing palisading necrobiotic granulomatous pathology. The palisading granuloma is centred on the collagenolytic pathology and comprises lymphocytes and histiocytes. (Magnification 10×).
For skin lesions of granuloma annulare, she was prescribed oral pentoxifylline 400 mg three times a day. A physician’s opinion was sought for a raised sugar level, and she was put on a combination of oral metformin 500 mg and glimepiride 1 mg one time a day.
Granuloma annulare is one of the benign, non-infectious granulomatous diseases. Various morphological variants of granuloma annulare include localised, perforating, subcutaneous and generalised or disseminated.1 Localised granuloma annulare is the most common variant. The presence of a minimum of 10 annular plaques is considered to be a generalised or disseminated variant.2 Generalised granuloma annulare usually affects middle-aged women and is frequently associated with systemic disorders like diabetes mellitus, malignancies, thyroid disorders and infections.3 4 Disseminated (generalised) granuloma annulare is often associated with underlying diabetes mellitus and often precedes the onset of diabetes by a few years. Diabetes mellitus is associated with elevated inflammatory markers, especially interleukin 6, and T-cell and macrophage activation. A recent meta-analysis has shown a significant link between granuloma annulare and type 2 diabetes mellitus.5 Pentoxifylline is a phosphodiesterase inhibitor and has been used successfully for generalised granuloma annulare by Rubel et al, Pătraşcu et al, Kharkar et al and Nambiar et al.6–9
Learning points.
Disseminated granuloma annulare can be a cutaneous sign of diabetes mellitus.
Early detection and timely intervention can prevent metabolic and vascular complications of diabetes.
Footnotes
Twitter: @rashlessdoctor
Contributors: The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms and critical revision for important intellectual content: KR, BM, SRT and PK. The following authors gave final approval of the manuscript: KR, BM, SRT and PK.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Ethics statements
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Consent obtained directly from patient(s).
References
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