Besiana P. Beqo

Citation: Beqo BP, Haxhija EQ. Subcutaneous Granuloma Annulare in an Atypical Age Group in Immediate Post-Covid-19 Phase. Dermatol Pract Concept. 2023;13(2):e2023172. DOI: https://doi.org/10.5826/dpc.1302a172 Accepted: March 20, 2023; Published: April 2023 Copyright: ©2023 Beqo 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: Emir Haxhija MD PhD FEBPS, Department of Paediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, A-8036 Graz, Austria. Phone: +43-(0)316 – 38513762 Fax: +43-(0)316 – 38513775 Email: emir.haxhija@medunigraz.at This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Background and Objectives: This study aims to review how the introduction of propranolol as the primary treatment option for children with infantile hemangiomas (IHs) has affected the use of other treatment options at our institution and to determine the indications for surgical treatment of children with IHs in the propranolol era. Patients and Methods: The authors conducted a single-center, noncompeting, historical/retrospective cohort study to review all cases referred to the institution for IH evaluation from 2005 to 2020. The authors analyzed the complete charts of patients who received surgery from 2011 to 2020 and evaluated the reasons for each surgical intervention. Detailed descriptive statistics are provided. Logistic regression analysis and Pearson’s χ ²-test were applied. Results: During the study period, 592 children received treatment. From 2011, oral propranolol (n=268; 74%) and surgery (n=95; 26%) were the only treatments of choice for complicated IH cases. A significant decrease in the frequency of surgical treatment was observed (P=0.01). The authors identified four main indications for surgical treatment: (1) patients with ulceration and IH size appropriate for surgical resection (15%); (2) patients whose parents preferred surgical treatment (19%); (3) patients who presented late and underwent surgery before the age of three (29%); and (4) patients with sequelae after IH involution and excision after the third year of life (37%). Conclusions: Despite the significant decrease in the need for surgical treatment of children with IHs since the introduction of propranolol, there are still several clear indications for treating IH cases where surgery plays a crucial role.

Objectives: Subcutaneous granuloma annulare (SGA) is a rare, self-limiting granulomatous disease in children, commonly diagnosed by histopathology following biopsy or surgical excision. This study aimed to identify imaging clues for SGA that could expedite accurate diagnosis and avoid the need for biopsy in children.Methods: We retrospectively analyzed complete hospital records of all children diagnosed with SGA at our institution from January 2001 to December 2020. Detailed disease history, imaging findings, management, and outcome were evaluated.Results: We identified 28 patients (20 girls) at a median age of 3.75 (range 1–12.5 years). Ten patients presented with multiple lesions. Most lesions were located on the lower extremities (n = 26/41). Ultrasound examinations were performed on all patients, and 12 (43%) patients also received an MRI. Surgical intervention was conducted in 18 (64%) patients either by incisional biopsy (n = 6) or total excision of the lump (n = 12). In all patients who did not undergo surgery, SGA resolved spontaneously. A careful review of the MRIs led to the discovery of a characteristic imaging shape of SGA lesions: the epifascial cap with a typical broad circular base laying on the fascia, extending towards the subdermal/dermal tissue. This distinctive shape was evident in every patient in our cohort.Conclusions: The “Epifascial Cap Sign” is a specific imaging sign for SGA, which to the best of our knowledge, helps distinguish this disease from other subcutaneous lesions. Recognition of this novel diagnostic sign combined with the historical and physical findings should enable clinicians to establish SGA diagnosis easily and diminish the need for further invasive diagnostic procedures.

Objectives. There are various subcutaneous lesions in children and often there is difficulty in obtaining an accurate diagnosis by non-invasive diagnostic procedures. Subcutaneous granuloma annulare (SGA) is a rare granulomatous disease that, even after imaging, is often mistaken for a low-flow subcutaneous vascular malformation (SVM). This study aimed to accurately identify clinical and imaging clues to distinguish SGA from low-flow SVM. Methods. We retrospectively analyzed complete hospital records of all children with a confirmed diagnosis of SGA and low-flow SVM who underwent MR imaging at our institution from January 2001 to December 2020. Their disease history, clinical and imaging findings, management, and outcome were evaluated. Results. Among 57 patients with granuloma annulare, we identified 12 patients (nine girls) with a confirmed SGA diagnosis who underwent a preoperative MRI. Their median age was 3.25 years (range 2–5 years). Of 455 patients diagnosed with vascular malformations, 90 had malformations limited to the subcutaneous area. Among them only 47 patients with low-flow SVM were included in the study and further analyzed. Our SGA cohort had a female predilection (75%) and a short history of lump appearance of 1.5 months. SGA lesions were immobile and firm. Before MRI, patients underwent initial evaluation by ultrasound (100%) and X-ray (50%). Surgical tissue sampling was performed in all SGA patients to establish a diagnosis. All 47 patients with low-flow SVM were diagnosed correctly by MRI. A total of 45 patients (96%) underwent surgical resection of the SVM. A careful retrospective review of imaging findings of patients with SGA and SVM showed that SGA present as homogenous lesions in the shape of an epifascial cap with a typical broad fascial base extending towards the subdermal tissue in the middle of the lesion. In contrast, SVMs always present with variable-sized multicystic or tubular areas. Conclusions. Our study shows clear clinical and imaging differences between low-flow SVMs and SGA. SGA presents characteristically in the shape of a homogenous “epifascial cap,” which distinguishes these lesions from multicystic heterogenous SVMs.

Zusammenfassung: Das Granuloma anulare (GA) ist eine seltene, gutartige, selbstlimitierende granulomatöse Erkrankung des kutanen und subkutanen Gewebes, die in verschiedenen Varianten vorkommt und alle Altersgruppen betrifft. Die lokalisierte Variante des GA ist durch Pappeln mit typischem ringförmigem Aussehen gekennzeichnet und ist insbesondere für einen Dermatologen leicht zu diagnostizieren. Die subkutane Form des GA tritt fast exklusiv im Kindesalter auf und findet sich auf gut exponierten, dem Trauma leicht zugänglichen Körperstellen, wie Schienbeinvorderseite, ulnare Unterarmseite, Schädel, Hände und Füße. Diese Läsionen können nach einigen Monaten verschwinden oder auch jahrelang verbleiben. Es werden im Rahmen der Abklärung unterschiedliche bildgebende Verfahren angewendet und letztendlich wird zur Diagnosesicherung oft auch die Chirurgie benötigt, wie im folgenden Fallbeispiel illustriert wird. Die Erstvorstellung eines Mädchens erfolgte im Alter von 3,5 Jahren aufgrund einer seit 2 Monaten nach einem Sturz aufgetretenen prätibialen Schwellung rechts. Aufgrund der derben Konsistenz der schmerzlosen Vorwölbung wurden eine Röntgenaufnahme, eine Ultraschalluntersuchung und ein Magnetresonanztomogramm in Narkose durchgeführt, die allesamt eine unspezifische epifasziale subkutane Weichteilläsion zeigten. Eine weiterführende Biopsie in Narkose ergab die Diagnose des subkutanen GA. Im weiteren Verlauf entwickelte das Mädchen in den nächsten 10 Jahren noch mehrere subkutane und kutane GA-Läsionen, die sich allesamt von selbst zurückbildeten. Bei subkutanen Läsionen an den für das subkutane GA typischen Stellen, insbesondere prätibial, sollte es möglich sein, dass diese Diagnose klinisch vermutet wird und den Patienten somit ein chirurgischer Eingriff zur Diagnosesicherung in der Regel erspart bleibt.

Infants with hypertrophic pyloric stenosis are usually diagnosed at about 3 to 8 weeks of age. The clinical onset of symptoms in preterm babies is observed normally at a later age than in term or post-term newborns. This report describes a rare case of a 2-day old preterm twin girl presenting with drinking laziness and recurrent vomiting. Five days after the beginning of symptoms and after several studies, including an upper gastrointestinal contrast study, the diagnosis of hypertrophic pyloric stenosis was made and confirmed at surgery. The postoperative course was uneventful. Interestingly, the mother of the child herself had a history of postnatal surgery on her fifth day of life due to congenital hypertrophic pyloric stenosis. To our best knowledge, this is the first report in the literature describing congenital hypertrophic pyloric stenosis in a mother and her child.