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  Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 142-146  

Multiple erythematous nodules: An intriguing entity


1 Department of Dermatology, Venereology and Leprology, Nagpur, Maharashtra, India
2 Department of Pathology, Government Medical College, Nagpur, Maharashtra, India

Date of Submission05-May-2020
Date of Decision20-Jul-2020
Date of Acceptance12-Sep-2020
Date of Web Publication16-Jan-2021

Correspondence Address:
Vaishali H Wankhade
Associate Professor, Department of Dermatology, Venereology and Leprology, Government Medical College and Hospital, Nagpur - 440 003, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/idoj.IDOJ_348_20

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   Abstract 


Pyogenic granuloma (PG), also called a lobular capillary hemangioma, is a benign vascular proliferation of skin or mucous membrane. It classically presents as a solitary friable nodule over the face or distal extremities. Multiple disseminated PG is a rare form generally reported after trauma such as burn injury. We report two cases of spontaneous development of multiple localized PGs in immunocompetent individuals.

Keywords: Eruptive pyogenic granuloma, multiple erythematous papulo-nodules, spontaneous


How to cite this article:
Supekar BB, Wankhade VH, Chopkar AD, Singh RP, Bhat D. Multiple erythematous nodules: An intriguing entity. Indian Dermatol Online J 2021;12:142-6

How to cite this URL:
Supekar BB, Wankhade VH, Chopkar AD, Singh RP, Bhat D. Multiple erythematous nodules: An intriguing entity. Indian Dermatol Online J [serial online] 2021 [cited 2021 Feb 26];12:142-6. Available from: https://www.idoj.in/text.asp?2021/12/1/142/307166




   Introduction Top


Pyogenic granuloma (PG, also known as granuloma pyogenicum, lobular capillary hemangioma, or telangiectatic granuloma) is a benign vascular proliferation of the skin and mucous membranes. It is a misnomer as it is neither infectious nor granulomatous.[1] Although PG may occur over normal skin, it is considered as a reactive hyper proliferative vascular response to minor trauma. Although the development of PG after trauma to the skin is very common, spontaneous development of multiple PG have been rarely reported in the literature.


   Case 1 Top


A 66-year-old female patient presented with multiple reddish raised lesions over right forearm of 6 months duration. Initially, she developed a single reddish raised lesion which gradually increased in size with the appearance of new lesions in the vicinity of the initial lesion. She gave a history of intermittent bleeding on trivial trauma. She denied history of any drug intake, preexisting skin lesion since birth, trauma prior to the onset of lesions, or any previous treatment taken for the same. She did not have any other cutaneous or systemic findings. On cutaneous examination, there were multiple erythematous, soft to firm, non tender, sessile nodules ranging from size 6 mm to 15 mm and ulceration with crusting at places, present over the extensor aspect of the right forearm [Figure 1]a. In addition, there were multiple erythematous papules with satellite lesions [Figure 1]b. On the basis of history and cutaneous examination, differential diagnoses of PG, angiokeratoma, bacillary angiomatosis, and Kaposi's sarcoma were considered. Dermoscopy was performed using 3 Gen Dermlite DL4 (CA, USA) in 10× polarized mode. Dermoscopy of nodular lesions revealed homogenous reddish areas with rail lines with ulceration at places surrounded by white collarette suggestive of PG, which was further confirmed on histopathology [Figure 2]a, [Figure 2]b, [Figure 2]c. Histopathological examination of nodule over the forearm revealed multiple lobules of proliferating capillaries in the dermis and deeper tissues with focal inflammatory infiltrate, suggestive of pyogenic granuloma (PG) [Figure 3]a and [Figure 3]b. Warthin–Starry stain was done to rule out bacillary angiomatosis and revealed no organism. No underlying arteriovenous malformation was detected on local ultrasonography. General and systemic examination was normal. Routine hematological investigations such as complete hemogram, liver, and renal function tests were within normal limits. Serology for HIV was nonreactive. On the basis of clinical, dermoscopic, and histopathological findings, a final diagnosis of localized multiple eruptive PGs was reached. The patient was treated with cryosurgery using liquid nitrogen as the cryogen. There was a significant resolution of nodular lesions after three sessions of cryotherapy, given 2 weeks apart [Figure 4]a and [Figure 4]b.
Figure 1: (a and b): Multiple erythematous, soft to firm, nontender, sessile nodules ranging from size 6 mm to 15 mm and ulceration with crusting at places over the extensor aspect of right forearm (a). Multiple erythematous papules and satellite lesions (b)

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Figure 2: (a-c): Dermoscopy (3 Gen Dermlite DL4 (CA, USA) 10× polarized mode) of nodular lesions revealed rail lines (black star), ulceration (yellow star), and white collarette (black arrow)(a), homogenous reddish areas (yellow arrow) surrounded by white collarette (black arrow)(b), ulceration (yellow star) and white collarette (black arrow) (c), suggestive of PG

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Figure 3: (a and b): Histopathological examination of nodule over forearm revealed multiple lobules of proliferating capillaries in the dermis and deeper tissues with focal inflammatory infiltrate, suggestive of PG [H and E, (a: 10× and b: 40×)]

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Figure 4: (a and b): Pre (a) and post treatment images (b) of nodular lesions in case 1 after 3 sessions of cryotherapy

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Case 2

A 27-year-old male presented with 3 months' history of multiple reddish raised lesions over the forehead. He gave a history of intermittent bleeding during combing or manipulation. On cutaneous examination, there were multiple erythematous, soft to firm, nontender, smooth-surfaced nodules ranging from size 10–20mm present over the right half of forehead [Figure 5]a and [Figure 5]b. On the basis of history and cutaneous examination, differential diagnosis of PG, angiokeratoma, and bacillary angiomatosis was considered. Histopathological examination of nodule over forehead revealed multiple dilated vascular clefts in the dermis separated by septae and myxoid stroma, suggestive of PG [Figure 6]a and [Figure 6]b. Warthin–Starrystain of the section did not reveal any organism. No underlying arteriovenous malformation was detected on local ultrasonography and Doppler study. General and systemic examination was normal. Routine hematological investigations such as complete hemogram, liver, and renal function tests were within normal limits. On the basis of history, clinical, and histopathological findings, a diagnosis of multiple localized eruptive PGs was reached. The patient was referred to surgery for excision considering the size of the lesion.
Figure 5: (a and b): Multiple erythematous, soft to firm, nontender, smooth-surfaced nodules ranging from size 10–20 mm present over right half of forehead

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Figure 6: (a and b): Histopathological examination of nodule over forehead revealed multiple dilated vascular clefts in the dermis separated by septae and myxoid stroma, suggestive of PG [H and E, (a: 10× and b: 40×)]

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   Discussion Top


PG is a common acquired benign angiomatous proliferation of the skin and mucous membranes that develops spontaneously. It was first described by Poncet and Dor in 1897. It usually affects children and young adults, sometimes pregnant women, and rarely elderly individuals.[2] The commonest sites of involvement are face, especially lips and extremities, mainly fingers, upper trunk, head, and perianal area.[3] Our first case is a 65-year-old female with multiple PGs over forearm, while second case is a 24-year-old male with multiple PGs over the forehead. It usually starts as a friable papule eventually growing over weeks to months, finally stabilizing into an erythematous nodule. The friable structure is prone to bleeding and ulceration. Occasionally, nodules may spontaneously involute.[4] The size varies between 5 mm and 10 mm, sometimes even reaching up to 50 mm. It is considered as a reactive hyper proliferative vascular response to a variety of stimuli such as infection, trauma, increased levels of female sex hormones, viral oncogenes, microscopic arteriovenous anastomosis, and growth factors. Local trauma or tissue injury is followed by sequential phases of wound healing with the activation of early inflammatory phase leading to the release of cytokines and growth factors that include vascular endothelial growth factor (VEGF).[5] It is followed by a proliferative phase, with the formation of granulation tissue and remodeling phase in which the granulation tissue is replaced by a scar. Godfraind et al.[6] suggested that PG may result from tissue injury or local trauma, followed by a dysregulated wound healing process, during which vascular growth is driven byFLT4 (VEGF signaling) and nitric oxidepathways.[6] Retinoids, antineoplastic, and antiretroviral medications have also been implicated in the pathogenesis.[7] It usually presents as a solitary papule, but multiple lesions and satellitosis, although unusual, might be present. Other theories focus on an imbalance between angiogenic promoters and inhibitors which leads to capillary overgrowth. There maybe overexpression of phosphorylated ATF2 and stat 3.[8] Eruptive PG can be classified as localized occurring in specific regions and disseminated or widespread.[9] Localized eruptive PG have been reported at sites of trauma, burns, within port wine stain, particularly after treatment with pulsed dye laser. The disseminated eruption is characterized by the acute appearance of multiple widespread lesions either spontaneously[10] or in the context of retinoid therapy, burn injury, pregnancy, or presence of antiphospholipid antibodies.[11] They have also been reported in association with malignancies like multiple myeloma, Hodgkin's disease, chronic lymphocytic leukemia, and disseminated melanoma.[12],[13] In both of our cases, the spontaneous occurrence of multiple and satellite lesions is an interesting feature. In the first case, lesions were confined to the right forearm, while the second case had multiple smaller lesions over the right frontal area, in which combing of hair might have triggered the development of satellite lesions. PG is dermoscopically characterized by homogenous reddish or white-red areas, whitish rail lines surrounded by whitish collarette in majority of the case.[14] Similar observations were reported in our case. Reddish homogenous areas may be attributed to the presence of numerous small capillaries or proliferating vessels in a myxoid stroma. White collarette is a ring shaped or arcuate squamous structure that corresponds to the hyperplastic adnexal epithelium that partially or totally embraces the lesion at the periphery.[15] White rail lines correspond histologically to fibrous septa that surround the capillary lobule in advanced cases. The vascular patterns described in PGs are linear, regular, dotted, or polymorphous atypical vessels. The differential diagnoses of such lesions include bacillary angiomatosis, disseminated atypical mycobacterial infections, and Kaposi's sarcoma which can be ruled out by histopathological and/or microbiological cultures [Table 1]. The lesions often resolve spontaneously within months to years. Treatment options include excision, curettage, electrodessication, laser surgery, sclerotherapy, and cryotherapy.[16] Our first case has shown significant resolution after treatment with cryotherapy without any complication. Multiplicity or satellite lesions of PG are uncommon and if multiple lesions appear, they develop around the site of recently treated lesions, more as a phenomenon of recurrence. They may develop after treatment with excision, shave excision, electrodesiccation, ligation, curettage, cautery, and CO2laser. Multiple eruptive with satellite PGs have also been rarely reported in patients with skin trauma, after burns, its treatment, and lightning injuries.[17],[18],[19],[20] However, there is a paucity of literature describing the spontaneous occurrence of multiple PGs. Sethuraman et al.[3] reported two patients of PG with the spontaneous occurrence of multiple and satellite lesions. Thus, we report these two cases because of its rarity. Our report also highlights the utility of dermoscopy, which helps in the diagnosis of such lesions.
Table 1: Differential diagnoses of multiple pyogenic granulomas

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Ballin JS, Egan KM, Satter EK: What is yourdiagnosis? Recurrent lobular capillary hemangioma with satellitosis (Warner and Wilson-Jones syndrome). Cutis 2014;93:125,132-3.  Back to cited text no. 1
    
2.
Itin PH, Fluckiger R, Zbinden R, Frei R. Recurrent pyogenic granuloma with satellitosis–a localized variant of bacillary angiomatosis? Dermatology 1994;189:409-12.  Back to cited text no. 2
    
3.
Sethuraman G, Khaitan BK, Sirka CS, Prasad H, Agarwal S, Singh MK, et al. Pyogenic granuloma with multiple and satellite lesions. Indian J Dermatol 2006;51:134-6.  Back to cited text no. 3
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Lin RL, Janniger CK. Pyogenic granuloma. Cutis 2004;74:229-33.  Back to cited text no. 4
    
5.
Werner S, Grose R. Regulation of wound healing by growth factors and cytokines. Physiol Rev 2003;83:835-70.  Back to cited text no. 5
    
6.
Godfraind C, Calicchio ML, Kozakewich H. Pyogenic granuloma, an impaired wound healing process, linked to vascular growth driven by FLT4 and the nitric oxide pathway. Mod Pathol 2013;26:247-55.  Back to cited text no. 6
    
7.
Piraccini BM, Bellavista S, Misciali C, Tosti A, De BerkerD, Richert B. Periungual and subungual pyogenic granuloma. Br J Dermatol 2010;163:941-53.  Back to cited text no. 7
    
8.
Chen SY, Takeuchi S, Urabe K, Hayashida S, Kido M, Tomoeda H, et al. Overexpression of phosphorylated-ATF2 and STAT3 in cutaneous angiosarcoma and pyogenic granuloma. J Cutan Pathol 2008;35:722-30.  Back to cited text no. 8
    
9.
Palmero ML, Pope E. Eruptive pyogenic granulomas developingafter drug hypersensitivity reaction. J Am Acad Dermatol 2009;60:855-7.  Back to cited text no. 9
    
10.
Shah M, Kingston TP, Cotteril JA. Eruptive pyogenic granulomas: A successfully treated patient and review of the literature. Br J Dermatol 1995;133:795-6.  Back to cited text no. 10
    
11.
Liao WJ, Fan PS, Fu M, Gao TW, Liu YF, Ikeda S. Clinicopathological and ultrastructural study of multiple lobular capillary hemangioma after scalding. Dermatology 2006;213:34-36.  Back to cited text no. 11
    
12.
Zak FC, Solomon A, Fellner MJ. Viscero cutaneous angiomatosis with dysproteinemic phagocytosis: Its relation to Kaposi's sarcoma and lymphoproliferative disorders. J Pathol Bacteriol 1966;92:594-99.  Back to cited text no. 12
    
13.
Pembroke AC, Grice K, Levantine AV, Warin AP. Eruptive angiomata in malignant disease. Clin Exp Dermatol 1978;3:147-56.  Back to cited text no. 13
    
14.
Zaballo P, Carulla M, Ozdemir F, Zalaudek I, Banuls J, Llambrich A, et al. Dermoscopy of pyogenic granuloma: A morphological study. Br J Dermatol 2010;163:1229-37.  Back to cited text no. 14
    
15.
Zaballos P, Llambrich A, Cuellar F, Puig S, Malvehy J. Dermoscopic findings in pyogenic granuloma. Br J Dermatol 2006;154:1108-11.  Back to cited text no. 15
    
16.
Pagliai KA, Cohen BA. Pyogenic granuloma in children. Pediatr Dermatol 2004;21:10-13.  Back to cited text no. 16
    
17.
Behne K, Robertson I, Weedon D. Disseminated lobular capillary haemangioma. Australas Dermatol 2002;43:297-300.  Back to cited text no. 17
    
18.
Allen RK, Rodman OG. Pyogenic granuloma recurrent with satellite lesions. J Dermatol Surg Oncol 1979;5:490-493.  Back to cited text no. 18
    
19.
Netchiporouk E, Moreau L, Ramirez LP, Castillo PA, Bravo FP, Del Solar MC, et al. Eruptive disseminated pyogenic granulomas following lightning injury. Dermatology 2015;23:199-203.  Back to cited text no. 19
    
20.
Pitarch G, Pérez-Ferriols A, Millán F. Recurrent pyogenic granuloma. Actas Dermosifiliogr 2012;103:536-39.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1]



 

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