Abstract:

Granuloma annulare (GA) is a granulomatous inflammatory dermatosis with numerable associations and a complex pathogenesis. The relationship between GA and metabolic abnormalities, as well as its temporal association with various malignancies, remains unclear with several contradictory studies. Previously GA, due to its co-existence with and eruption prior to relapse of lymphoproliferative disorders, had been considered a potential harbinger of such malignancies. Herein, we report a case of localized GA after autologous stem cell transplantation (AHSCT) for treatment of relapsed Hodgkin’s lymphoma, nodular sclerosing type (NSHL). Two years after initial treatment with doxorubicin, vinblastine, dacarbazine and brentuximab our patient noted supraclavicular lymphadenopathy, biopsy of which showed recurrence of NSHL. She subsequently underwent chemotherapy and a conditioning regimen followed by AHSCT. Pruritic erythematous papules were first noted over the bilateral posterior neck. Punch biopsy revealed palisading histiocytic infiltrates with increased dermal mucin consistent with granuloma annulare. Stains for microorganisms were all negative. CD30 and CD15 stains, given her NSHL, were also negative. Two recent studies have shown increased expression of Th1 and JAK-STAT pathway mediators, predominantly tumor necrosis factor (TNF)-?, interleukin (IL)-1?, interferon (IFN)-? in GA lesional skin. Investigations into cytokine alterations in non-Hodgkin lymphoma and various autoimmune conditions treated with AHSCT have shown significant changes in the inflammatory milieu, including IL-6, IL-8 and TNF-? in the early post transplant period. Allogeneic HSCT patients similarly have elevations in the aforementioned pro-inflammatory cytokines with a peak between weeks 2 to 3, temporally relating to our patient’s eruption. The exact inflammatory cascade precipitating this patient’s GA remains unknown but our case highlights only the second reported case of GA after AHSCT.

Financial Disclosure:
No current or relevant financial relationships exist.

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Eric Kowalski, MD