Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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Prof. Somashekhar Nimbalkar
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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
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Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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C.S. Ramesh Babu,
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Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : July | Volume : 15 | Issue : 7 | Page : EC01 - EC06 Full Version

Study of Histomorphological Spectrum of Granulomatous Lesions of Skin


Published: July 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/48484.15059
Lalit Kumar, Pooja Agarwal, Tarun Mishra, Yatendra Chahar, Raj Kamal, Shikha Tyagi, Nupur Kaushik

1. Junior Resident, Department of Pathology, S.N. Medical College, Agra, Uttar Pradesh, India. 2. Professor, Department of Pathology, S.N. Medical College, Agra, Uttar Pradesh, India. 3. Assistant Professor, Department of Pathology, S.N. Medical College, Agra, Uttar Pradesh, India. 4. Assistant Professor, Department of SKIN&V.D., S.N. Medical College, Agra, Uttar Pradesh, India. 5. Dy. Director/Scientist-E (Medical), Department of Health Research, National JALMA Institute For Leprosy and Other Mycobacterial Diseases (I.C.M.R), Agra, Uttar Pradesh, India. 6. Junior Resident, Department of Biochemistry, Autonomous State Medical College Society, Firozabad, Agra, Uttar Pradesh, India. 7. Junior Resident, Department of Pathology, S.N. Medical College, Agra, Uttar Pradesh, India.

Correspondence Address :
Dr. Pooja Agarwal,
79, Gandhi Nagar, By Pass Road, Agra-282003, Uttar Pradesh, India.
E-mail: drpooja.agarwal@gmail.com

Abstract

Introduction: The granulomatous reaction is defined as a distinctive inflammatory pattern characterised by the granuloma. The term Granuloma was first coined by Virchow in 1864. The granuloma is characterised by collection of activated histiocytes, epithelioid cells and multinucleate giant cells that may or may not be rimed by lymphocytes and/or show central necrosis. The pattern of skin disease varies from one country to another and across different parts within same country. The granulomatous lesions of skin are a common and intriguing problem in developing countries.

Aim: To study the histomorphological spectrum of granulomatous lesions of skin.

Materials and Methods: This cross-sectional study was conducted in Department of Pathology, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India, over a period of two years (from September 2018 to September 2020). All skin biopsies coming to the Department of Pathology were fixed in 10% neutral buffered formalin for duration of 12 to 24 hours. Paraffin wax blocks were made and 3-4 micrometer section were taken and stained with Haematoxylin and Eosin (H&E), showing granulomas on histology were included in the study. On H&E, stained slide, granulomas were studied for type, morphology and site. Special stains were used for further evaluations and analysis.

Results: Out of total 124 cases studied, the maximum patients 34 (27.41%) were of 11-20 years age group. The epithelioid granuloma was the most common type in 76 (61.29%) cases followed by histiocytic granuloma in 24 (19.35%). The infectious granulomatous dermatoses were the most common histological type in which tuberculosis was most common followed by leprosy. Most commonly the lesions were found to involve the whole dermis in 74 (59.68%) cases, followed by upper and mid dermis in 35 (28.22%) cases. Out of 40 cases of leprosy, 17 (42.50%) cases were found Wade-Fite Stain positive. Out of total 57 cases of tuberculosis, 31 (54.38%) cases were found Acid-Fast Bacillus (AFB) positive.

Conclusion: Authors concluded that major cause of granulomatous dermatoses in developing countries is still infectious, tuberculosis and leprosy being the leading causes. Histopathology is gold standard for diagnosis and categorisation of granulomatous dermatoses. Special stains are useful in cases of any dilemma.

Keywords

Dermatoses, Epithelioid granuloma, Histiocytic granuloma, Lupus vulgaris

Granulomatous inflammation was recognised as a distinct entity in the early 19th century and has been of continuing interest because it forms a common and intriguing problem clinically and pathologically (1). According to Dorland, the term ‘granulomatous’ was expressed initially by Virchow to describe a tumour like mass or nodule of granulation tissue (2). The occurrence of different types of granulomatous lesions of skin varies according to the geographical location and the pattern varies from one country to another and across different parts within same country. Granulomatous skin lesions arise due to chronic inflammatory response against various organic and inorganic antigens (3). The provocative agents of granulomatous inflammation are non degradable by both neutrophils and non activated macrophages.

The polymorphonuclear leukocytes and non activated macrophages are unable to digest and eradicate completely the offending agents, which results in activation of cell mediated type IV hypersensitivity reaction, activation of macrophages, T and B lymphocytes cells response with release of chemical mediators of inflammation mainly cytokines and leads to granuloma formation (4),(5). The granulomatous reaction is defined as a distinctive inflammatory pattern characterised by collection of activated histiocytes, epithelioid cells and multinucleate giant cells that may or may not be rimed by lymphocytes and/or show central necrosis (1). Granulomatous lesions of the skin are very common in our country and some may show overlapping histological features, for which special stains were done in this study. Therefore, this study was done to study the histomorphological spectrum of granulomatous lesions of skin and to study the aetiology of granulomatous lesions using special stains for tuberculosis and leprosy as and when required.

Material and Methods

This hospital based cross-sectional study was conducted in Department of Pathology, Sarojini Naidu Medical College Agra, Uttar Pradesh, India, over a period of two years (from September 2018 to September 2020). Ethical approval was obtained from Institute Ethical Committee (IEC/2021/12). All the biopsies received in histology laboratory of the Department of Pathology from Department of Dermatology revealing granulomas were studied.

Inclusion and Exclusion criteria: All skin biopsies coming during two-year study period from September 2018 to September 2020 revealing granulomas on histological examination were included in this study and inadequate biopsies were excluded from this study.

Methodology

The biopsy sample taken from clinically diagnosed granulomatous lesions of skin were transported immediately to histology laboratory in 10% formalin. Sample was fixed in 10% neutral buffered formalin for duration of 12 to 24 hours. Paraffin wax blocks were made and 3-4 micrometer sections were taken and stained with H&E. Special stains were done as and when required. Acid-Fast Bacteria (AFB)- Ziehl-Neelsen staining for Mycobacterium tuberculosis, AFB- Fite’s acid fast staining for leprosy, Periodic Acid-Schiff (PAS) staining for fungal infection, Brown Hoops modified gram staining for cat scratch disease, CD68 immunohistochemical staining for giant cell tumour of skin was done.

The standard enumeration of leprosy bacilli in lesions, the Bacterial Index (BI), was done according to standardised Ridley’s logarithmic scale (which applies to both skin biopsies and slit skin smears) (6).

• BI=0: no bacilli observed
• BI=1: 1 to 10 bacilli in 10 to 100 hpf*
• BI=2: 1 to 10 bacilli in 1 to 10 hpf*
• BI=3: 1 to 10 bacilli per hpf*
• BI=4: 10 to 100 bacilli per hpf*
• BI=5: 100 to 1,000 bacilli per hpf*
• BI=6: >1,000 bacilli per hpf*
*hpf= Oil emersion

Statistical Analysis

Data was entered in MS Excel and descriptive data was obtained.

Results

A total of 124 cases were included in this study, youngest patient encountered was six years of age and oldest patient encountered was 70 years of age. The maximum patients 34 (27.41%) were of 11-20 years age group, followed by 28 (22.58%) cases in 21-30 years of age group. Minimum number of cases was found below ten and above 60 years of age accounting seven (5.64%) and nine (7.26%) cases, respectively. Males 72 (58.06%) were more commonly affected than females 52 (41.94%).

In this study, out of total 124 cases, the most common site involved was trunk in 36 (29.03%) cases followed by lower limb in 32 (25.81%) cases. In tubercular granulomatous dermatoses, out of 57 cases the most common site involved was lower limb in 21 (36.84%) cases. In leprosy, out of 40 cases the most common site involved was trunk in 18 (45%) cases. In non infectious granulomatous dermatoses, out of 23 cases the most common site involved was head and neck region in eight (34.78%) cases (Table/Fig 1).

In this study, out of total 124 cases, the most common type of granuloma found was epithelioid granuloma in 76 (61.29%) cases out of which 27 (35.53%) had caseating necrosis. The second most common type of granuloma found was histiocytic granuloma in 24 (19.35%) cases followed by foreign body granuloma in 12 (9.67%) cases. Out of 124 cases, 31 (25%) cases had necrosis (27 had caseating and four had fibrinoid necrosis) (Table/Fig 2).

In this study, out of total 124 cases, infectious granulomatous dermatoses were seen in 101 (81.45%) cases and non nfectious in 23 (18.55%) cases. In infectious granulomatous dermatoses the most common histological diagnosis was tubercular granulomatous dermatoses followed by leprosy while in non infectious category the epidermoid cyst was the most common histological diagnosis.

Out of total 101 cases of infectious granulomatous dermatoses, the most common histological diagnosis was tubercular granulomatous dermatoses in 57 (56.44%) cases followed by leprosy in 40 (39.60%) cases. In tubercular granulomatous dermatoses, out of 57 cases, the most common was lupus vulgaris (Table/Fig 3). Out of total 57 cases of tubercular granulomatous dermatoses, 31 (54.38%) cases were found AFB positive (Table/Fig 4)a, b, c and (Table/Fig 5).

In leprosy, out of 40 cases, the most common was borderline tuberculoid leprosy in 13 (32.50%) cases followed by borderline lepromatous leprosy and lepromatous leprosy 7 (17.50%) cases each, tuberculoid leprosy 6 (15%) cases, mid borderline leprosy 5 (12.50%) cases and Indeterminate leprosy in 2 (5%) cases. According to Ridley Jopling classification (6) of leprosy, out of 40 cases, 17 (42.50%) cases were found Wade-Fite stain positive. Out of 17 cases, one cases of borderline tuberculoid leprosy, two cases of mid borderline leprosy and seven cases each of borderline lepromatous leprosy and lepromatous leprosy were positive (Table/Fig 6)a-d, (Table/Fig 7). One (0.99%) case each of Histoplasmosis, cutaneous leishmaniasis, cat scratch disease and granulomatous dermatoses (infectious-unclassified) was also encountered.

Out of 23 (18.55%) cases of non infectious granulomatous dermatoses, the most common histologic diagnosis was epidermoid cyst in 5 (21.74%) cases followed by sarcoidosis and Calcinosis cutis in 4 (17.39%) cases each, dermoid cyst and erythema nodosum in 3 (13.04%) cases each and 1 (4.34%) case each of actinic granuloma, granuloma annulare, rheumatoid nodule and giant cell tumour of skin (Table/Fig 8)a,b.

On histopathological examination, in our study the granulomatous dermatoses lesion of skin involved different part of dermis. Out of total 124 cases, most commonly the lesions were found to involve the whole dermis in 74 (59.68%) cases, followed by upper and mid dermis in 35 (28.22%) cases, mid and deep dermis in 10 (8.06%) cases, deep dermis in 3 (2.42%) cases and each 1 (0.81%) case involving upper dermis and upper and deep dermis. In tuberculosis and leprosy mostly lesions were found to involve whole dermis followed by upper and mid dermis. In noninfectious granulomatous dermatoses, mostly lesions were found to involve the whole dermis followed by mid and deep dermis (Table/Fig 9).

In this study, on histological examination authors found one case of cat scratch disease (Brown hoops modified gram stain positive), one of giant cell tumour of skin (CD68 positive), one of Histoplasmosis (PAS positive) and one case of granulomatous dermatoses (infectious unclassified) (both PAS and AFB negative) (Table/Fig 10), (Table/Fig 11) a,b, (Table/Fig 12).

Discussion

The distribution of granulomatous dermatoses varies widely according to geographic location (7). The granulomatous lesions of skin are a common and intriguing problem in developing countries and a diagnostic challenge to Dermatopathologists, since an identical histological pattern may be produced by several causes, and a single cause may produce several histological patterns (8). Various infectious and noninfectious granulomatous dermatoses are frequent among the population of western part of India (9). Granulomas usually form as a result of the persistence of a non degradable product or as the result of hypersensitivity response (4). They have considerable variation in microscopic appearance producing different pictures with in the same biopsy or from one lesion to another (10). The granulomatous inflammation is a type IV hypersensitivity reaction to an antigen and is defined as a special variety of chronic inflammation in which the mononuclear phagocytic cells take the form of macrophages, epithelioid cells and multinucleated giant cells admixed with other cells especially lymphocytes and plasma cells (9),(11). The epithelioid cells defined as mononuclear cells with ill-defined cell boundaries, oval to spindle nuclei with vesicular chromatin and finely granular eosinophilic cytoplasm are hallmark of delayed hypersensitivity granuloma. The multinucleated giant cells are a regular feature of granulomatous inflammation produced by fusion of macrophages (11). The complex interaction between invading organism or antigen, drug or other irritant, extended antigenaemia, macrophage activity, B cells over activity, TH1 cell response, circulating immune system and biological mediators results in granuloma (11). Different types of granulomas are found- sarcoidal granulomas, epithelioid granulomas, suppurative granulomas, palisading granulomas, foreign body granulomas and mixed cell granulomas (12).

Granulomatous dermatoses can be classified broadly into infectious and noninfectious categories. Infectious granulomatous dermatoses are further sub classified on the basis of morphology of granuloma and identification of infectious agents with the help of special stains (10). Histopathological examination is considered to be important tool in accurate diagnosis and classification of granulomatous dermatoses and still remains the gold standard. Good clinical history, a close histological examination and a clinicopathological correlation are essential in making a final diagnosis so that the appropriate treatment can be met. Special stains in conjunction with histology may also be required to reach an aetiological diagnosis (13).

In this study, maximum numbers of case were found in 11-20 years age group (27.41%, cases) followed by 21-30 years age group (22.58%, cases) which is comparable with Chakrabarti S et al., and Zafar MNU et al., who also encountered maximum cases in 11-20 years of age group (3),(14), while some studies found maximum number of cases in 21-30 years age group (1),(5),(7),(9),(15).

In this study, granulomatous dermatoses showed male predominance with male to female ratio 1.39:1. The present study was found concordant with Kumar VN et al., Chakrabarti S et al., Gulia SP et al., Ahmad F et al., Gupta K et al., Bal A et al., Pawale J et al., Gautam K et al., Singh R et al., Jayawardhana MPGN et al., and Makwana V et al., (1),(3),(5),(7),(9),(10),(15),(16),(17),(18),(19). The present study was nonconcordant with Bhattacharya A et al., and Zafar MNU et al., as they found female predominance (4),(14). In this study, the most common site of lesion was trunk followed by lower limb, while Zafar MNU et al., (14) found head and neck region to be the most common site followed by lower limb and Gupta K et al., (9) found upper limb as the most common site followed by head and neck region. This could be due to the geographical differences of the study place.

In this study, the most common type of granuloma was epithelioid granuloma (61.29%). The present study was found concordant with other studies (1),(3),(4),(9),(10),(14),(16),(19). The second most common type of granuloma was histiocytic which is concordant with Bhattacharya A et al., (4). Other authors have reported necrobiotic (3), suppurative (9),(10), foreign body type (1),(14),(16) and miscellaneous (19) as the second most common type of granuloma (Table/Fig 13).

In the present study, Infectious granulomatous dermatoses (81.45%) were more common than noninfectious (18.55%). The similar results were found by other authors (3),(4),(5),(9),(10),(16),(18). In the present study, tubercular granulomatous dermatoses (45.97%) were found to be the most common type followed by leprosy (32.26%) in infectious granulomatous dermatoses. This study was found concordant with Zafar M et al., and Pawale J et al., (14),(15). However, other authors Kumar VN et al., Chakrabarti S et al., Bhattacharya A et al., Gupta K et al., Bal A et al., Gautam K et al., Singh R et al., Jayawardhana MPGN et al., Bansal C et al., Mohan N et al., Dutta B et al., Khatib Y et al., Kumbar R et al., and Potekar RM. et al., found leprosy to be more common than tubercular granulomatous dermatoses (1),(3),(4),(9),(10),(16),(17),(18),(20),(21),(22),(23),(24),(25).

In the present study, lupus vulgaris was the most common type of tubercular granulomatous dermatoses followed by Tuberculosis Verrucosa Cutis. The similar results were found by many other authors (1),(3),(5),(9),(10),(14),(22),(23),(24),(26). Bhattacharya A et al., found scrofuloderma as the most common type (4). Jayawardhana MPGN et al., Bansal C et al., Mohan H et al., and Potekar RM et al., found lupus vulgaris cases only (18),(20),(21),(25).

In the present study, most common type of leprosy was borderline tuberculoid leprosy. The similar result was found by other studies (10),(21),(23),(25),(27),(28), however, Kumar A et al., reported mid borderline as the most common type (29) and Jayawardhana MPGN et al., found tuberculoid leprosy as most common type (Table/Fig 14) (18).

In the present study, foreign body granuloma was most the common type in noninfectious granulomatous dermatoses followed by sarcoidal granuloma. The present study was found compatible with Chakrabarti S et al., Zafar MNU et al., Pawale J et al., Gautam K et al., and Dutta B et al., (3),(14),(15),(16),(22). However, Bhattacharya A et al., and Makwana V et al., (4),(19) who found sarcoidosis as the most common histological diagnosis in noninfectious category, while other studies (18),(30) found granuloma annulare as the most common type.

In the present study, one case of cat scratch disease of skin was found, which was positive on Brown hoops modified gram stain while Khatib Y et al., also found one case of cat scratch disease of skin (23). In the present study, one case of giant cell tumour of skin was found, while no other study reported this entity. This tumour was positive for CD68.

In the present study, maximum number of cases 74 (59.68%) were found to involve the whole dermis followed by upper and mid dermis while Kumbar R et al., found upper dermis as the most common site in 83 (60.58%) cases followed by mid dermis (24).

In the present study AFB positivity was seen in 54.38% cases of tubercular granulomatous dermatoses, while other studies found AFB positivity as low as 5.0% (4),(10) cases to as high as 22.62% (15). The present study revealed a much higher incidence of AFB positivity.

In the present study, out of 40 cases of leprosy 17 (42.50%) were found Fite stain positive while 23 cases were negative. The present study was found concordant with Gupta K et al., and Suri SK et al., (9),(28). Fite stain positivity in other studies has varied from as low as 16.91% (1) to as high as 56.66% (15). In the present study, special stains were used in 115 (92.74%) cases and they aided in the correct histological diagnosis.

Limitation(s)

Limitation of the present study was lack of clinico-histologic correlation and absence of follow-up.

Conclusion

Major cause of granulomatous dermatoses in developing countries is still infectious, tuberculosis and leprosy being the leading cause, unlike the spectrum of developed countries. Since both these entities are curable, early and timely diagnosis is the mainstay of the treatment. H&E along with special stains can help in reaching the accurate diagnosis in majority of cases.

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DOI and Others

10.7860/JCDR/2021/48484.15059

Date of Submission: Jan 11, 2021
Date of Peer Review: Mar 10, 2021
Date of Acceptance: May 03, 2021
Date of Publishing: Jul 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jan 12, 2021
• Manual Googling: May 01, 2021
• iThenticate Software: May 26, 2021 (18%)

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