10.5826/dpc.1204a156
text/xml
2160-9381
1999
en
Karamvir Yadav
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Granuloma Annulare, Covid-19, SARS-Cov-2, Palisading granuloma, Subcutaneous GA
Subcutaneous Granuloma Annulare in an Atypical Age Group in Immediate Post-COVID Phase
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2022-10-31
2021-08-28
2022-10-31
2023-03-20
e2022156
Dermatol Pract Concept
Karamvir Yadav
2022/10/31
10.5826/dpc.1204a156
e2022156
Department of Medicine, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India 
2160-9381
Granuloma Annulare, Covid-19, SARS-Cov-2, Palisading granuloma, Subcutaneous GA
en
e2022156
Subcutaneous Granuloma Annulare in an Atypical Age Group in Immediate Post-COVID Phase
https://dpcj.org/index.php/dpc/article/download/1999/1790
   Subcutaneous Granuloma Annulare in an Atypical
     Age Group in Immediate Post-Covid-19 Phase
      Lovleen Kaur1, Disha Chakraborty1, Surabhi Dayal2, Sunita Singh3, Karamvir Yadav4


1 Department of Dermatology, Venereology and Leprology, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak,
  Haryana, India
2 Department of Dermatology, Venereology and Leprology, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India
3 Department of Pathology, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India
4 Department of Medicine, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India



Key words: Granuloma Annulare, Covid-19, SARS-Cov-2, Palisading granuloma, Subcutaneous GA
Citation: Kaur L, Chakraborty D, Dayal S, Singh S, Yadav K. Subcutaneous Granuloma Annulare in an Atypical Age Group in Immediate
Post-Covid-19 Phase. Dermatol Pract Concept. 2022;12(4):e2022156. DOI: https://doi.org/10.5826/dpc.1204a156
Accepted: January 7, 2022; Published: October 2022
Copyright: ©2022 Kaur et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Lovleen Kaur, MD, Senior Resident, Department of Dermatology, Venereology and Leprology, Pt. B.D. Sharma Post
Graduate Institute of Medical Sciences, Rohtak, Haryana, India. Email: dr.lovleen555@gmail.com




Introduction                                                             the onset. There was no ulceration/ discharge from the
                                                                         nodules. Twenty days earlier, he had fever, sore-throat, mal-
Granuloma Annulare (GA) is a benign, self-limiting, chronic              aise, body-aches and anosmia (Positive Rapid Antigen test
granulomatous disorder. Viruses are one of the triggering                for SARS-Cov-2). Patient received symptomatic treatment
factors. Only two case reports of SARS-Cov-2 triggered GA                (Paracetamol and Etoricoxib) under home-isolation. SARS-
are reported till date; one- in an adult (localized GA) and              Cov-2 infection was also present in wife and daughter.
another localized, generalized and subcutaneous GA (SCGA)                     Clinically, there were 23 discrete, subcutaneous nodules,
in pediatric patients [1,2]. SCGA is rare in adults, especially          firm to hard, non-tender, non-fluctuant, mobile, symmetri-
geriatric population.                                                    cally distributed predominantly over extensors of bilateral
                                                                         thighs and few on legs, upper-arms and abdomen. Majority

Case Presentation                                                        were appreciated on palpation only while few lesions had
                                                                         erythematous hue. The largest lesion measured 4 x 3 cm2
A 63-year-old male presented with abrupt onset, multiple,                over right upper thigh whereas others varied from 1 x 1 to
asymptomatic, skin-colored to erythematous nodules involv-               1.5 x 2 cm2 (Figure 1). Routine biochemistry, hemogram,
ing abdomen, bilateral upper and lower limbs for 7 days.                 anti-­streptolysin O titres, and Mantoux test were normal.
Lesions progressed rapidly without systemic complaints ex-               C-reactive protein and ESR were high. SARS-Cov-2 IgG
cept for malaise. Patient denied insect bite/ trauma before              titre was 64 AU/mL(positive). Serology for HBV, HCV,
                                                                         ­




Research Letter | Dermatol Pract Concept. 2022;12(4):e2022156                                                                        1
               Figure 1. (A) Marked subcutaneous nodules on bilateral thighs which were better appreciated on palpa-
               tion only (red arrow depicts biopsy site). (B) Faintly erythematous nodules on medial aspect of left thigh
               and lower leg (black arrows).




               Figure 2. (A) Normal epidermis, perivascular lympho-histiocytic infiltrate in the dermis (blue arrow) and
               palisading of histiocytes in subcutaneous fat (red arrow) on H&E, 40x. (B) Interstitial infiltrate of lym-
               phocytes and histiocytes with focal palisading and mucinous degeneration in subcutaneous fat marked
               by red arrow (H&E, 100x).




HIV, ­Parvovirus-B19, HSV-1 and 2, EBV, CMV, Adenovi-                 Conclusions
rus, M
     ­ ycoplasma pneumoniae, ricketssiosis were negative.
­Considering the age, he was investigated for any associated          SCGA commonly affects trauma-prone sites like extensors of
malignancy. CECT-Chest revealed subtle ground glass opac-             distal extremities. In our case it involved proximal upper and
ities in bilateral upper lobes and fibro-atelectatic bands in         lower extremities, and abdomen. Possibility of drugs incit-
apical zones suggesting post-covid sequelae. CECT-Abdomen             ing SCGA is unlikely as patient had taken Paracetamol and
and pelvis were normal. Deep incisional skin biopsy consid-           Etoricoxib in past without any dermatological complaints.
ering differential diagnosis of Erythema Nodosum (EN),                The conspicuous absence of lesional pain, tenderness, er-
Subcutaneous Sweet Syndrome and SCGA was performed.                   ythema and concomitant systemic features ruled out EN
­Histopathology was consistent with SCGA (Figure 2). ­Alcian          and Sweet syndrome. Absence of vasculitis on histopathol-
Blue staining was also positive for mucin. Intralesional tri-         ogy eliminates causes of ‘septal panniculitis with vasculitis’.
amcinolone acetonide (10mg/ml) was injected in divided                Histopathologically, positive Alcian blue stain for mucin
sittings after informed consent from the patient resulting in         excludes differential of Miescher Radial Granuloma of EN.
complete remission within fifteen days.                               Although, rheumatoid nodules are also asymptomatic and



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simulates SCGA on histopathology, the former has more           References
­fibrin deposition than mucin causing ‘red’ granulomas unlike
‘blue’ granulomas in SCGA.                                      1. García-Gil MF, Monte Serrano J, García García M, Matovelle
                                                                   Ochoa C, Ara-Martín M. Granuloma annulare triggered by SARS-
   SARS-Cov-2 induces cytokine storm, producing IL-1β,
                                                                   CoV-2 infection. The first reported case. J Dermatol. 2021;48(1):e1-
IL-6, TNF-α, IL-12/23 which may precipitate SCGA as a re-
                                                                   e2. DOI:10.1111/1346-8138.15594. PMID: 331​69426.
active phenomenon. Vascular damage associated with ­viruses     2. Mazzotta F, Troccoli T, Bonifazi E. Granuloma annulare and
causing immune-complex deposition may also explain                 SARS-CoV-2 pandemic. Eur J Pediat Dermatol. 2020;30(2):83-87.
chronic granulomatous changes seen in GA. To conclude,             DOI: 10.26326/2281-9649.30.2.2105.
geriatric SCGA may be another dermatological manifesta-
tion triggered by SARS-Cov-2. It may enforce a huge diag-
nostic dilemma in the elderly confusing it with ­cutaneous
metastasis necessitating meticulous diagnostic workup.




Research Letter | Dermatol Pract Concept. 2022;12(4):e2022156                                                                       3
