Abstract:

Granuloma annulare (GA) and Necrobiosis lipoidica (NL) are idiopathic granulomatous diseases which may be associated with diabetes mellitus (DM), other conditions or occur in isolation. Published reports of synchronous or metachronous GA and NL in the same patient have prompted speculation about a relationship between the two. We report the case of a 60-year-old woman with poorly controlled Type 2 DM and a 6-year history of asymptomatic dull, red to violaceous plaques on both legs, with progressive involvement of the upper arms and abdomen. The clinical morphology of the eruption ranged from raised annular lesions on the abdomen, resembling GA, to centrally atrophic plaques on the legs, resembling NL. A punch biopsy of an abdominal lesion demonstrated classical features of GA, including localized interstitial and palisading granulomatous inflammation in the upper dermis associated with increased mucin deposition. A simultaneous punch biopsy of a lesion on the foot revealed typical features of NL including a pan-dermal, tiered pattern of palisading granulomatous inflammation with zones of altered collagen and a lymphoplasmacytic infiltrate. Reports of synchronous GA and NL in the diabetic setting, or otherwise, are rare, with only 11 cases described in the literature. Our case represents an additional example of this concurrence in a diabetic patient. We suspect that the co-existence

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or sequential development of GA and NL in the same individual is under-reported. Given the histopathological overlap between both entities and the periodic difficulty in distinguishing one from the other, we propose that they are variations on the same theme.

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Thai Yen Ly, MD