Facial Abrikosoff tumour: The role of the dermatologist during COVID‐19 pandemic

1.

Dear Editors,

The outbreak of the infection caused by severe acute respiratory syndrome coronavirus (SARS‐CoV‐2) and the consequent coronavirus disease (COVID‐19) has radically changed the way physicians approach outpatient care. ¹ While writing this article, Italy is one of the European countries with the highest number of cases with almost 220 000 positive subjects since the start of the pandemic. Considering that cutaneous manifestations of COVID‐19 have begun to be reported, outpatient dermatology departments are at high risk of admitting coronavirus positive patients. Among the measures suggested for the prevention of the diffusion of the virus, a complete reschedule of dermatological outpatient activity has been undertaken restricting hospital access only to emergent visits and postponing non‐urgent consultations. While this approach has been vital in reducing viral spreading, thanks to a drastic reduction in patient flow among the different hospital facilities, it also has its downsides. We report the case of a 26‐year‐old female who presented for the rapid appearance of a mass on her face. Even though it had grown considerably, the patient had decided to neglect it given the difficulty in acceding to hospital facilities during the COVID‐19 pandemic. Upon clinical examination, a nodule of 2 × 1.5 cm² was noted in the glabellar area. The lesion was slightly tender upon palpation, single, firm, skin‐coloured, mobile, and with well‐defined borders. The overlying skin showed no relevant change (Figure 1A). Her past medical history was otherwise unremarkable as were her laboratory examinations. Given the rapid volumetric increase, the lesion was excised and pathological examination was performed. Histologically, the biopsy showed a non‐encapsulated dermal tumour characterised by a proliferation of polyhedral cells, some arranged in a plexiform pattern. The overlying epidermis appeared to be hyperplastic. The cells presented an abundant eosinophilic granular cytoplasm and exhibited, on immunohistochemistry, strong and specific staining with S100 and CD68. Cytological atypia in the granular cell component was absent as well as the mitotic activity (Figure 1B,C). The patient reported no adverse events during the postoperative recovery and no local recurrence has occurred at the time of writing this paper. A diagnosis of granular cell tumour (GCT), also known as Abrikosoff's tumour, ² was made. This is a rare benign neoplasm of neural sheath origin, ³ which generally affects females with Fitzpatrick's skin type V or VI between the second and fifth decades of life. ⁴ GCTs can affect both the mucosa and skin and are commonly located on the tongue (40% of cases), upper respiratory tract, breast, and upper extremities. ⁵ Other affected locations are the gastrointestinal tract, the respiratory tract, the thyroid gland, the urinary bladder, the central nervous system, and the female genitalia. ⁶ They mostly present as an asymptomatic slowly growing nodule. The diagnosis can be made by histopathological examination of the lesion, as the clinical findings are mostly non‐specific. For this reason, the differential diagnosis is wide and includes adnexal tumours, lipoma, dermatofibroma, neurofibroma, and schwannoma. Histologically, the tumour is characterised by large eosinophilic cells with a granular cytoplasm—hence, the name GCT. Immunohistochemical stains are generally positive for S100, neuron‐specific enolase, and vimentin. ⁷ The COVID‐19 pandemic has reduced hospital accesses to only urgent procedures. The risk with this practice lies in the execution of a correct triage. The appearance of a rapidly enlarging nodule should warrant the execution of dermatological examination within reasonable times. Even though the lesion turned out to be benign, GCTs have shown malignant transformation, albeit rarely (1%‐2% of cases). ⁸ The use of correct personal protective equipment is fundamental to enable dermatologists to actively participate in the sanitary crises. While colleagues are busy fighting SARS‐CoV‐2 directly, dermatologists should not stand aside and contribute to the correct and rapid diagnosis of cutaneous disease giving their fundamental support for preventive health care measures.

FIGURE 1.

A, Nodule of 2 × 1.5 cm² was noted in the glabellar area. The lesion was slightly tender upon palpation, single, firm, skin‐coloured, mobile, and with well‐defined borders. The overlying skin showed no relevant change. B, Non‐encapsulated dermal tumour characterised by granular cell. Typically, the overlying epidermis appeared to be hyperplastic. C, Characteristically, granular cell surrounds the follicle

2. CONFLICT OF INTEREST

The authors declare no conflicts of interest.