Skin granuloma

Introduction Most of the reported skin Hodgkin's disease, cutis lymphogranulomatosis, is actually a type A lymphomatoid papulosis. Synonymous Hodgkin lymphoma, Hodgkin granuloma, Hodgkin paragranuloma, Hodgkin sarcoma, lymphogranulomatosis maligna. The disease is a kind of ML, with special tumor giant cells (Reed-Sternberg cells, referred to as RS cells), often with varying degrees of inflammatory cell infiltration. There are quite a lot of overlapping performances in these two diseases. Type A cells of lymphomatoid papulosis share a common immunophenotypic marker with Reed-Sternberg cells (RS cells). Lymphoma-like papulosis can be seen in patients with Hodgkin's disease. Primary skin Hodgkin's disease without lymph node involvement is difficult to confirm and is very rare.

Cause

(1) Causes of the disease

The cause of this disease is still unclear. Here are some thoughts:

1. Viral infection: The incidence of people who are in close contact with patients is high. Lerine et al. proposed that the serum EB virus antibody titer in patients is increased, which is considered to be related to EB virus infection, but there is no clear evidence.

2. Radiation effects: The incidence of residents in the atomic bomb explosion area is four times higher than that of other residents.

3. May be associated with other types of ML, multiple idiopathic hemorrhagic sarcoma or leukemia.

4. Cellular immunodeficiency: according to the patient's blood T lymphocyte reduction, cellular immune hypoplasia, normal delayed type hypersensitivity disappeared, slow rejection of allografts, early lesions often occur from the lymph node T region, considered to be immune monitoring with T cells Functional defects lead to abnormal tumor hyperplasia of "reticular cells".

(two) pathogenesis

The pathogenesis is still unclear. Since there is still debate about the origin of RS cells, it needs further discussion. The origin of RS cells is thought to come from T lymphocytes, B lymphocytes, tissue cells or interdigitated reticulocytes or dendritic reticulocytes. Most of them tend to come from reticulocytes, but they have not been confirmed.

an examination

Related inspection

Intradermal test skin lesions

Patients often complain of superficial lymph nodes or lymph nodes, especially in the neck, painless progressive swelling, accompanied by fatigue, loss of appetite, weight loss, irregular hypothermia, night sweats and itching. Late stages can involve any organ. Due to the swelling of the neck and axillary lymph nodes, the brachial plexus can be compressed to cause cough, difficulty in breathing, superior vena cava syndrome, and difficulty in speech. Involvement of the spleen can cause abdominal discomfort, indigestion, nausea, vomiting, and symptoms caused by hypersplenism. Involvement of bones can cause fractures, exophthalmos, spinal cord compression and paralysis. Central nervous system involvement can cause hemiplegia, peripheral neuropathy and pain. Gastrointestinal involvement can cause ulcers, pain, bleeding, obstruction, and malabsorption syndrome. Involving the liver can cause jaundice and hepatic coma. Involvement in the genitourinary system can cause uremia. Patients with low cellular immunity are prone to infection by viruses, bacteria and candida.

Skin damage can be divided into specific and non-specific.

1. Specific damage: According to statistics from Benninghoff et al, it is seen in 5% to 10% of patients. Primary is rare. Most of them are derived from blood sources, which are common in advanced patients with extensive lymph node lesions; if they are retrogradely transmitted by the corresponding lymph nodes, they can be seen in the early stage. Primary lesions can occur before other symptoms, including lymphadenopathy in a few months or 5 to 10 years, with a better prognosis, and patients can survive for 10 to 20 years. Patients with secondary damage often die within a few months. Damage occurs in the upper part of the scalp, neck and trunk, and can manifest as papules, nodules, plaques, erythroderma or eczema, occasional or subcutaneous nodules. Ulcers can occur on the basis of nodules or plaques, or from skin lesions such as lymph nodes or bones.

2. Non-specific damage: more common, often manifested as epidermal erosion, erythema, mossy, pruritic or erythroderma. Other damages such as pale skin, urticaria, polymorphous erythema, nodular erythema, red pityriasis, pemphigus, ichthyosis, dermatomyositis, and skin dysplasia may also occur. Sometimes it can also express purpura, bullae, lymphedema, alopecia, palmar keratosis, and phlebitis and pigmentation. Due to the low cellular immune function, at least about 15% of patients develop herpes zoster.

Most Hodgkin's disease usually originates in lymph nodes, extending retrogradely from the lymph nodes or lymphatic vessels to the skin or directly to the skin. Skin lesions are papules or nodules with or without ulceration. In the advanced cases, skin miliary dissemination can occur. Non-specific skin lesions are common in patients with Hodgkin's disease. Generalized severe pruritus can occur several months before the disease or after the disease has been clearly diagnosed. Secondary nodular pruritus and pigmentation can occur due to scratching. Other skin manifestations such as acquired ichthyosis, exfoliative dermatitis and generalized herpes zoster.

Non-specific skin lesions have no specificity in clinical or histopathology. The clinical morphology of specific skin lesions is not specific, and the diagnosis is mainly confirmed by histopathological examination.

Differential diagnosis

Common granulomas:

Sexually transmitted lymphogranuloma, also known as inguinal lymphogranuloma, is a sexually transmitted disease caused by infection with Chlamydia trachomatis. The disease usually occurs in tropical and subtropical regions of the world, especially in South America, Africa and Southeast Asia.

Eosinophilic granuloma (EG) is an abnormal differentiation of non-tumor properties of isolated tissue cells. Eosinophilic granuloma is a manifestation of Langerhans cell hyperplasia, formerly known as histiocytosis X. Eosinophilic granuloma occurs mostly in children 5-10 years of age, with parts of the bones and lungs. This accounts for 60-80% of cases of Langerhans cell hyperplasia. Blacks are rare.

Non-eosinophilic granulomatous prostatitis is a non-cheese granuloma, which is centrally liquefied and necrotic. There are major tissue cells in the proximal gland lumen, surrounded by lymphocytes, plasma cells and eosinophils.

In the past, sputum buds have been mistakenly referred to as sputum-like bacteriosis, and have been confirmed to be a tumor that originates in cutaneous helper T lymphocytes. It occurs mostly in young adults, but it also occurs in people over 10 years old or 60 years old, with more men than women. There are three types, the most common of which is the development of tumors from plaques or plaques, or tumors directly, called sudden sputum granuloma, which develops rapidly and has a poor prognosis. About 10% of cases can develop erythroderma, called erythrodermic mycosis fungoides. The disease can last from a few months to several years, with an average of 4-10 years.

Granuloma annulare is a benign inflammatory skin lesion of unknown etiology that occurs in the dermis or subcutaneous tissue and is characterized by ring-shaped papules or nodular lesions.

Patients often complain of superficial lymph nodes or lymph nodes, especially in the neck, painless progressive swelling, accompanied by fatigue, loss of appetite, weight loss, irregular hypothermia, night sweats and itching. Late stages can involve any organ. Due to the swelling of the neck and axillary lymph nodes, the brachial plexus can be compressed to cause cough, difficulty in breathing, superior vena cava syndrome, and difficulty in speech. Involvement of the spleen can cause abdominal discomfort, indigestion, nausea, vomiting, and symptoms caused by hypersplenism. Involvement of bones can cause fractures, exophthalmos, spinal cord compression and paralysis. Central nervous system involvement can cause hemiplegia, peripheral neuropathy and pain. Gastrointestinal involvement can cause ulcers, pain, bleeding, obstruction, and malabsorption syndrome. Involving the liver can cause jaundice and hepatic coma. Involvement in the genitourinary system can cause uremia. Patients with low cellular immunity are prone to infection by viruses, bacteria and candida.

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