Collagenolytic (necrobiotic) granulomas: part II – the ‘red’ granulomas

Abstract

A collagenolytic or necrobiotic non-infectious granuloma is one in which a granulomatous infiltrate develops around a central area of altered collagen and elastic fibers. The altered fibers lose their distinct boundaries and exhibit new staining patterns, becoming either more basophilic or eosinophilic. Within the area of altered collagen, there may be deposition of acellular substances such as mucin (blue) or fibrin (red), or there may be neutrophils with nuclear dust (blue), eosinophils (red), or flame figures (red). These color distinctions can be used as a simple algorithm for the diagnosis of collagenolytic granulomas, i.e. 'blue' granulomas vs. 'red' granulomas. Eight diagnoses are included within these two groupings, which are discussed in this two-part article. In the previously published first part, the clinical presentation, pathogenesis and histologic features of the 'blue' collagenolytic granulomas were discussed. These are the lesions of granuloma annulare, Wegener's granulomatosis, and rheumatoid vasculitis. In this second half of the series, the 'red' collagenolytic granulomas are discussed; these are the lesions of necrobiosis lipoidica, necrobiotic xanthogranuloma, rheumatoid nodules, Churg-Strauss syndrome, and eosinophilic cellulitis (Well's Syndrome).Lynch JM, Barrett TL. Collagenolytic (necrobiotic) granulomas: part II -the 'red' granulomas.

Non-Infectious Granulomatous Diseases of the Skin and their Associated Systemic Diseases

“…[52] Other malignancies associated with NXG include mycosis fungoides, lymphoma, and leukemia. [53] While malignancy is clearly a concern for NXG patients, it is important to consider systemic involvement of NXG, which has been shown to involve a number of organs including the heart and lung, in addition to the kidney, liver, intestine, spleen, ovary, pharynx, and or retro-orbital skull. [53,54] It may be prudent to consider evaluation of these patients for systemic involvement with MRI, echocardiography, and chest x-ray.…”

Necrobiosis Lipoidica

“…The palisading pattern is more common in cases associated with diabetes. 35,36 The alteration of connective tissue referred as necrobiosis. The altered collagen appears paler with a grayer hue and more impact than normal collagen.…”

“…The palisading pattern is characterized by single or multiple layers of hyalinized or necrobiotic collagen surrounded by a rim of noninflammatory cells in the lower two-thirds of the dermis producing a sandwich or wedding cake pattern. 35 Vascular alteration, lipid droplets, and giant cells are often present. 36 The pseudotuberculoid pattern of NL consists of less necrobiotic collagen and more epithelioid histiocytes with an increased number of lymphocytes, plasma cells, and giant cells.…”

“…4). 35 Direct immunofluorescence will show deposits in the vasculature consisting of IgM, IgA, C 3 , fibrinogen, and only rarely IgG. The immunofluorescence finding in NL is nonspecific and controversial.…”

Necrobiosis lipoidica in diabetic patients: pathogenetic and clinical features

“…Имеются данные о том, что женщины болеют в три раза чаще, чем мужчины [8]. Первые симптомы дерматоза обычно возникают в возрасте от 20 до 60 лет, хотя он может развиваться как у детей, так и у лиц старшего возраста [5].…”