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Dermpath-India

Foreign Body Granuloma of the Skin

Dr Sampurna Roy MD          

 

                                                                                                                      

 

 

A foreign body granuloma is a reaction to exogenous (foreign) or endogenous materials that are too large to be ingested by macrophages.

These localized lesions  may occur at any age and clinically present as papules, plaques or nodules.

Examples of granulomas due to exogenous material:

Starch- (Maltese cross birefringence in polarized light).

Talc - Birefringent

Suture material - (nylon, silk, dacron)- birefringent refractile multicoloured.

Wood splinter or bone fragment- Special stains for microorganisms should  be performed to rule out infection due to contamination.

Plant material can be identified by PAS stain.

Arthropod bite can cause granulomatous reaction.

Silica (glass or sand), zirconium and beryllium elicit sarcoidal granulomatous reaction.

Tattoo material- Extracellular pigment is identified and may induce local sarcoidal granulomas.

Tetanus toxoid (aluminium-adsorbed vaccines) may induce foreign body reaction.

Granular debris at the centre surrounded by histiocytes and lymphoid infiltrate with follicle and eosinophils at the periphery.

May resemble Kimura's disease.

Silicone granulomas: A silicone granuloma is a tissue reaction elicited by silicone.  Silicone granuloma in the breast arises from leakage of prosthesis.

Foreign body giant cells are present near lacunar spaces filled with amorphous refractile material. 

Path Quiz Case 56.

 

Examples of granulomas due to endogenous material:

Calcium deposits: Urates- Gouty Tophus - Path Quiz Case 57  Oxalate. :

 

Keratin and hair : Granulomatous inflammation is present adjacent to ruptured epidermal and pilar cyst, pilomatrixomas and dermoid cyst.

    

Damaged hair follicle can elicit granulomatous reaction.

Fragments of keratin may be identified in the dermis.

Hair shafts are round or oval shaped on section, birefringent and Ziehl- Neelson stain positive.

Note: Foreign body reaction to keratin is an indication for a careful search for residual squamous cell carcinoma or recurrent tumour in a patient with history of carcinoma.

Histological feature:

Initially there is suppuration around the foreign material.

This is followed by granulomatous inflammation  which may be tuberculoid, sarcoidal, suppurative or necrobiotic type.

In the later stage there is fibrosis.

Around the foreign material there are histiocytes, some of these have differentiated into large cells with indistinct cell boundaries called epithelioid cells.

There are multinucleated giant cell of foreign body-type often containing ingested foreign material.

In foreign body giant cells the nuclei are scattered irregularly throughout the cytoplasm.

A few Langhans type of giant  cells may be present, in which the nuclei are distributed along the periphery in a semicircle.

Diagnostic clue:

In most cases foreign material can be recognized in Hematoxylin and eosin stain sections.

In difficult cases (granulomatous inflammation of skin or panniculitis in which the nature cannot be diagnosed) polarized light should be used to identify birefringent foreign material.

Differential diagnosis:  

Granulomatous inflammation in deep fungal infection, atypical mycobacteria or leishmaniasis may simulate features of foreign body reaction.

Special stains for microorganisms are useful in establishing the diagnosis.

 

Further reading

A foreign body aspiration in a preschool child mimicking a multitrigger wheezing: a case report and review of the literature.

Foreign body granuloma caused by hyaluronic acid/dextranomer microsphere filler injection.

A foreign body aspiration in a preschool child mimicking a multitrigger wheezing: a case report and review of the literature.

Histopathologic patterns associated with external agents.

Mycobacterium fortuitum cutaneous infection from amateur tattoo.

Pigmented epidermal cyst with dense collection of melanin: A rare entity - Report of a case with review of the literature.

Facial self-induced paraffinoma in an elderly woman.

Tattoos: natural history and histopathology of cutaneous reactions.

Role for trauma in inducing pencil "lead" granuloma in the skin.

Unusual palisading and necrotizing granulomas associated with a lubricating agent used in lipoplasty.

 

 

 

Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)


 

 

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