Introduction

The granulomatous inflammatory disorders are distinct type of chronic inflammatory processes where there is distinctive presence of granulomas. Granulomas are formed by accumulation of epithelioid type histiocyte, inflammatory cells and multinucleated giant cells.^[1] Firstly granulomatous term was used by Virchow to describe a granule like tumor mass of granulation tissue.^[2] Granulomatous inflammation is classified as type IV hypersensitivity reaction and can be induced by various kinds of infections, autoimmune, toxic, allergic and neoplastic conditions.

Different types are granulomatous inflammatory lesion of skin are seen in different geographic locations.^[3],^[4] A single etiology can produce varied histological features and conversely many granulomatous skin lesion with almost similar histological features can have different etiologies.^[5] So cutaneous granulomatous lesion often present as a diagnostic challenge to pathologists and dermatologists. Granulomatous dermatoses due to infectious causes are very common and leprosy and tuberculosis are the leading etiologies.^[6] Histopathology with routine and special stains play important role in identifying the specific infectious agent^[1] and in classification of Hansen disease.^[7],^[8]

This study was conducted with the aim to evaluate the frequency and patterns of different cutaneous granulomatous lesions with its clinico-histopathological correlation to reach etiological diagnosis.

Material and Methods

70 cutaneous lesion biopsies showing granuloma formation studied retrospectically in “Department of Pathology, Teerthanker Mahaveer Medical college and research center, Moradabad” in duration of 2 years and 2 months from November 2016 to January 2019. Clinical findings and other related information were obtained from requisition forms of biopsies received.

Cutaneous biopsies were routinely processed and stained with H&E and special histochemical stains like Ziehl Neelsen (ZN), Fite Faraco(FF), Periodic Acid Schiff(PAS), Gomori Methenamine Silver(GMS) wherever necessary. Skin lesions having granuloma formation histopathologically were involved in the study. Cases without any granuloma formation and inadequate biopsies were excluded. Cases of cutaneous granulomatous lesion were studied on the basis of their histopathological and clinical findings.

Results

Among 70 cases were studied in which male predominance was noted with 40(57%) cases and females constituted 30(43%) case providing M :F ratio of 1.3:1. Most of the patients were noted in age group of 21 to 30 years i.e 24(34.3%) cases followed by 15(21.43%) case in 31 to 40 years. 82% of cases were seen below 50 years of age in our study.

Infectious granulomatous dermatoses were very common, only one case of sarcoidosis was found. Most cases of infectious dermatoses were noted in 21 to 30 years comprising 24(34.3%) cases. Leprosy remained the significant causative reason for infectious granulomatous dermatoses succeeded by tuberculosis of skin.

Borderline tuberculoid leprosy was found to be predominant, constituting 16 (22.86%) cases followed by indeterminate and lepromatous leprosy both had 14(20%) cases, tuberculoid leprosy 13(18.57%) case and 8(11.43%) of orderline lepromatous. In cases of leprosy, lepra bacilli were found to be positive in 21 cases by Fite Faraco stain. Lupus vulgaris constituted 2 cases (2.86%) and only one (1.43%) case of sarcoidosis was found.

Discussion

Granuloma formation is due to type IV hypersensitivity reaction elicited by infectious and non infectious antigen. Granulomatous dermatoses are common in North India with overlapping clinical presentations. So, it becomes important to catch the definitive etiological diagnosis for their treatment.^[9] Histopathology plays a pivotal role for confirmatory diagnosis like in several diseases of other system of the body.^[6]

The distribution of granulomatous dematoses varies widely according to geographic location. Very less number of studies done on the infectious granulomatous dermatoses, showing broad statistical variation for several lesions.

This study is comparable to Gautam et al,^[7] Pawale et al,^[10] and Dhar et al^[11] in finding of predominance of male in granulomatous skin lesion showing male(57%), female(43%) with M:F ratio of 1.3:1. Infectious granulomatous dermatoses were commonest in this study which is similar with the study by Bal et al.^[12],^[13] Common est site of the skin lesions was upper extremity which is comparable with the study done by Gautam et al^[7] but not with Zafar et al^[14] in which most lesion were found in head and neck region.

P resent study shows leprosy as the commonest etiological diagnosis 67(95.71%) cases succeeded by cutaneous tuberculosis 2(2.86%). Mh El Khalwary et al^[9] concluded 40.8% cases showing cutaneous tuberculosis followed by 31.7% case of leprosy. Rubina Qureshi et al^[13] concluded cutaneous leishmaniasis 56.7% as the leading cause of granulomatous dermatoses followed by 13.5% case of lupus vulgaris. Bal et al^[12] and Potekar et al^[15] concluded leprosy as a leading cause of cutaneous granulomatous disease. The observations in this study is similar with the findings of studies by Bal et al^[12] and Potekar et al^[15] done in India.

In our study the commonest subtype of leprosy was found to be borderline tuberculoid 16(22.86%) cases which is comparable with the findings of Gautam et al^[7] 46.7% cases, Bal et al^[12] 55.2% cases and Chakrabarti^[16] et al 57.94% cases. On Morphology non-caseating granulomas were found in all the tuberculoid as well as in borderline tuberculoid leprosy which were same as granulomas in tuberculosis and sarcoidosis. Out of all 67 cases of leprosy, on Fite Faraco stain 21 cases were found to be positive. Strong positivity noted in all cases for lepromatous leprosy on Fite Faraco stain. Borderline tuberculoid leprosy show positivity in 3 cases for Fite Faraco stain but none in tuberculoid leprosy.

Granulomatous infiltration of nerve bundle, arrector pili muscle and adnexa along with proper clinical findings were helpful in the diagnosis of tuberculoid and borderline tuberculoid leprosy.

Cutaneous tuberculosis was the second commonest granulo matous dermatoses in this study, 2(2.86%) cases were diagnosed as lupus vulgaris were found to be negative on Ziehl Neelsen stain. Bal et al^[12] found 5% positivity Z-N staining in cases of Lupus vulgaris. Z-N staining is specific for acid fast bacilli, still its positivity is low and varies with different studies. The present study did not revealed any case of cutaneous leishmaniasis. Rubina et al^[13] found 56.7% cases in Pakistan. In this study one case was reported as cutaneous sarcoidosis based on epithelioid cell granuloma without caseastion and presence of inflammatory cells or Langhans giant cells. In this study there was 1 (1.43%) case of sarcoidosis somewhat similar to reported by Gautam et al^[7] 1.88%.

In the present study two cases of fungal granuloma was noted similar to Potekar et al.^[15] Different studies reported fungal cutaneous granuloma in span of 2.7%to 3.3%.^[6],^[7],^[13],^[17],^[18],^[19]

Conclusion

Etiology of granulomatous dermatoses varies greatly according to geographic distribution. Infectious form of granulomatous dermatoses are important causes with leprosy as the commonest etiology. Clinically granulomatous skin lesions have overlapping presentations. Histopathology plays a pivtol role in the diagnosis and sub-classification of cutaneous granulomatous lesion, along with the proper history and relevant clinical examination. Special stains play supportive role. Our study reports the various important chronic granulomatous inflammatory dermatoses in this region of North India, which will be beneficial for management and implicating the health programmes.