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A Journal on Dermatology and Sexually Transmitted Diseases

Official Journal of the Italian Society of Dermatology and Sexually Transmitted Diseases
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Giornale Italiano di Dermatologia e Venereologia 1999 December;134(6):639-42

language: Italian

Perforating gra­nu­lo­ma annu­lare (PGA) in HIV-ser­o­pos­i­tive ­patient

D'antuono A., Lehmann J., Passarini B., De Tommaso S., Carlà E.

Università degli Studi - Bologna, Dipartimento di Medicina Clinica, Specialistica e Sperimentale, Sezione di Dermatologia


Perforating gra­nu­lo­ma annu­lare (PGA) is an uncom­mon var­i­ant of gra­nu­lo­ma annu­lare of ­unknown aetio­lo­gy char­ac­ter­ized by ery­them­a­tous or ­flesh-col­ored ­papules in annu­lar ­groups local­ized ­most fre­quent­ly on ­hands and ­feet. These ­lesions ­present a cen­tral umbil­i­ca­tion ­with ulcer­a­tion and ­release of necrob­i­ot­ic mate­ri­al. In the lit­er­a­ture ­only a few cas­es of PGA in HIV-ser­o­pos­i­tive ­patients ­have ­been ­found. There are char­ac­ter­is­tic immu­no­log­ic abnor­mal­ities com­mon to all HIV-serop­o­sit­ve ­patients. These ­include aner­gy to ­delayed-­type hyper­sen­si­tiv­ity ­skin ­tests, a poly­clo­nal ­increase in IgG, and deple­tion of periph­er­al help­er\induc­er T lym­pho­cytes. This ­results in a sig­nif­i­cant reduc­tion in ­cell-medi­at­ed immu­nity. This immu­no­sup­pres­sion has ­lead to a pro­found ­increase in the num­ber of oppor­tu­nis­tic infec­tions and neo­plasms. Umbert and Winkelmannn ­have sug­gest­ed ­that ­cell-medi­at­ed immu­nity is ­involved in the path­o­gen­e­sis of gra­nu­lo­ma annu­lare. There is ­some evi­dence sug­gest­ing a ­delayed hyper­sen­si­tiv­ity reac­tion and a vas­cu­lar inju­ry in the path­o­gen­e­sis of per­fo­rat­ing gra­nu­lo­ma annu­lare, but the ­role of cel­lu­lar-medi­at­ed immu­nity in the path­o­gen­e­sis of PGA is ­still dis­cussed. The ­case is ­described of homo­sex­u­al HIV-pos­i­tive ­patient ­observed for the ­onset of a pap­u­lar and pap­u­lar-ves­cic­u­lar erup­tion local­ized on ­hands and ­feet. General con­di­tion and labor­a­to­ry find­ings indi­cat­ed a ­severe immu­no­def­i­cien­cy. The his­to­path­o­log­ic find­ings of ­some of ­these ­lesions con­firmed the sug­ges­tive pat­tern of PGA. In ­this ­patient the der­mat­o­sis was auto­res­olv­ing. There are two ­types of PGA: one ­type is char­ac­ter­ized by mul­ti­ple umbil­i­cat­ed pap­u­lar ­lesion (P-­type); the oth­er ­type ­appears ­less fre­quent­ly, con­sist­ing in ulcer­a­tions cov­ered by ­crust (U-­type). In ­these ­patients the fol­low­ing pro­gres­sive stag­es may be ­observed:ery­them­a­tous ­papules, ­which ­evolve ­into yel­low­ish, pus­tu­lar appear­ing ­lesion, ­which sub­se­quent­ly dis­charge a ­clear ­fluid. Histopathologic ­study ­showed per­fo­ra­tion of the epi­der­mis and tran­sep­i­the­lial ­release of the abnor­mal necrob­i­ot­ic mate­ri­al. Although the dis­ease is usu­al­ly ­self-lim­it­ed, a ­wide ­array of treat­ment meth­ods has ­been ­employed to try to has­ten res­o­lu­tion.

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