Widespread Granuloma Annulare and Cervical Adenocarcinoma

Correspondence

Widespread Granuloma Annulare and Cervical Adenocarcinoma

References 1. Lo JS, Guitart J, Bergfeld WF. Granuloma annulare associated with metastatic adenocarcinoma. Int J Dermatol 1991; 30:281-283. 2. Harman RRM. Hodgkin's disease, seminoma of testicle and widespread granuloma annulare. Br J Dermatol 1977;97(suppl 15):50-51. 3. Dabski K, Winkelmann RK. Generalized granuloma annulare: ciinicai and laboratory findings in 100 patients. ) Am Acad Dermatol 1989; 20:39-47. 4. Schwartz RA, Hansen RC, Lynch PJ. Hodgkin's disease and granuloma annulare. Arch Dermatol 1981; 117: 18.S-186. 5. Stewart KA, Cooper PH, Greer KE, et al. Granuloma annulare temporally associated with carcinoma of the breast. J Am Acad Dermatol 1989; 21:309-311.

To the Editor: Lo et al.' reported a case of granuloma iinnulure in a patient with metastatic iidenocarcinoma of the colon. Although the two diseases might be fortuitously associated, the authors postulate that malignancy or immunosuppressive therapy may provide favorable conditions for the development of granuloma annulare. We observed two cases of widespread granuloma annulare associated wrth cervical adenocarcinoma. Case I

A 42-ycar-old woman presented in I98S witli an :isymptomatic generalized eruption affecting the trunk and the extremities, which consisted of rose-colored papules, 2 to 5 mm large, most of which had a depressed center. Some of the lesions had an annular and arciform arrangement. The clinical diagnosis of widespread granuloma annulare was confirmed by the histologic examination. During the stay of the patient in the hospital, a cervical adenocarcinoma was diagnosed. Hysterectomy followed by chemotherapy resulted in a complete resolution of the skin eruption. The patient remained free of symptoms on subsequent examinations.

Coexistence of Familial Systemic Lupus Erythematosus and Localized Scleroderma To the Editor: The simultaneous occurrence of systemic lupus erythematosus (S1.1-) and localized scleroderma is rather uncommon. A patient displaying this unusual combination is described herein. Case Report A 58-year-old woman presented tt) the Dermatology Clinic at the Chaim Sheba Medical Center, Tel Hashomer, with a 2year history of slowly spreading cutaneous lesions on the back and abdomen. The patient had a I 7-year history of SI.E, which was diagnosed on the basis of nondeforming arthritis, and positive anti-nuclear and anti-double-stranded DNA antibodies. Additionally, the patient's two sisters and daughter suffered from SLL;, one of the sisters having died at the age of 28 from renal failure. Prior to being seen, the patient had received, on an intermittent basis, nonsteroidal anti-inflammatory drugs and oral steroids. Physical examination was normal apart from the presence of a niidsystolic click and a late systolic murmur, which were best heard over the left sternal border. CAitaneous examination revealed the presence of two welldefined, pigmented, nontender, indurative plaques on the lower back and right lower abdomen, measuring approximately 8 cm in diameter. Laboratory examinations, including coruplere blood count, i;sR blood chemistry, urinalysis, C3, C4, and CH50, were within normal limits. ANA, however, was positive (++, 1/40 speckled pattern, substrate: rat liver cells) while anti DS-DNA was 9% (normal < 15%). Chest x-ray, upper gastrointestinal series, ElXi and lung function studies were all normal. Echocardiography showed mitral valve prolapse. Skin biopsy showed sclerosis of the whole dermis, thick and homogenous collagen bundles being seen in conjunction vvith obliteration of the cutaneous appendages. Thus, the histologic appearance was typical of scleroderma. No treatment was initiated for these lesions and, to date, following 2 years of observation, no further lesions have appeared.

Case 2 A 38-year-old woman underwent surgical treatment for cervical adenocarcinoma in Airgust I9S7. She was referred to us in September the same year for evaluation of a widespread skin eruption that had been present for 6 months. It consisted of erythematous papules coalescing into annular plaques and involving mainly the dorsal aspects of the extremities. Histologic examination was consistent with granuloma annulare. The eruption r-esolved 2 months later under topical corticosteroid treatment and did not recur. Discussion Multiple pathogenetic factors have been ascribed to granuloma annulare, but no specific cause has been identified to date. An association of granuloma annulare and malignancy was first reported liy Harman in 1977.^ In a series of 100 patients with generalized granuloma annulare, Dahski and Winkelmann found 14 cases of internal malignancies preceding or following the skin eruption, hut they rejected a causative relationship between the two disorders on account of the wide variation in the time span between their onset.' A pathogenetic link between granuloma annulare and malignancy has been suggested by several authors.'•'•'•'' The simultaneous manifestation of the skin and neoplastic disorders in our two patients and their parallel course (i.e., resolution of the skin eruption following closely the extr.iction of the tumor) are arguments in favor of the concept that granuloma annulare may be paraneoplastic in some cases. Snejina Vassileva, M.D., Ph.L^. Maya Krasteva, M.D. Sonia Marina, M.D., Ph.D. Nikolai Tsankov, M.D., Ph.D. Sofia, Bulgaria 819