Generalized granuloma annulare - A rare cutaneous marker of AIDS.

Sir,

Granuloma annulare (GA) is a benign, usually self-limiting, necrobiotic disorder of unknown aetiology. Clinical variants of GA are localized, generalized, subcutaneous and perforating type. Generalized GA is a rare variant that represents 8.5-15% of all cases of GA. Generalized GA presents clinically with skin-colored, erythematous or violaceous dermal papules and/or small annular plaques with elevated borders. Various associations have been reported with GA, which include diabetes mellitus, malignancies, thyroid diseases, hepatitis B and C virus infection, drugs and acquired immunodeficiency syndrome.

A 45-year-old male patient farmer by occupation presented with generalized, multiple, asymptomatic skin-colored papules, annular and arciform plaque involving neck, back [Figure 1], chest [Figure 2], shoulder, upper and lower extremities since past 1 year. Patient also had multiple grouped vesicular lesions over erythematous base involving right thoracic dermatome. Patient also had multiple grouped hypopigmented macules involving left thoracic dermatome indicating healed lesions of Herpes zoster. History of multiple unprotected sexual exposures was present. Histopathological examination of skin biopsy from the annular plaque with H and E stain revealed diffuse palisading granulomas in upper dermis [Figure 3], special staining with PAS (Periodic Acid Schiff) stain revealed diffuse palisading granulomas with mucin deposits in upper dermis . ELISA test for HIV was positive. Blood sugar levels were normal. Blood VDRL in serial dilution was negative. Patients CD4 count was 34 cells/mm3.

Figure 1

Skin-colored papules, annular and arciform plaque involving back

Figure 2

Skin-colored papules, annular and arciform plaque involving chest

Figure 3

H and E stain revealed diffuse palisading granulomas in upper dermis ×10

GA was first described by Colcott Fox in 1895. It is a chronic cutaneous eruption that presents clinically as dermal papules, plaques or nodules due to various degenerative changes in dermis termed necrobiosis. It can be localized, perforating, generalized or subcutaneous.[1] Diabetes mellitus, iritis, sarcoidosis, autoimmune thyroiditis and various neoplasms have been found in association with GA.[2] GA with AIDS is being increasingly reported.[3] Generalized GA is the most common clinical pattern in HIV infection. GA associated with HIV can present at all stages of HIV infection, but it is slightly more common in patients with acquired immunodeficiency syndrome.[1] Resolution of generalized GA after the zidovudine therapy has also been reported. Rarely GA may be the first presenting sign of HIV infection.-[45] In our case even though patient had very low CD4 count with recurrent, multidermatomal herpes zoster and generalized GA, patient was in good health without any opportunistic infections.

In our case generalized GA was one of the prominent cutaneous markers of AIDS. Although generalized GA has been reported to be one of the common cutaneous markers of AIDS by foreign authors, it is not commonly seen to be associated with AIDS in Indian scenario. We are reporting this case due to paucity of Indian reports of generalized GA in AIDS.