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Granuloma annulare arising in association with pulmonary coccidioidomycosis

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Granuloma annulare arising in association with pulmonary coccidioidomycosis
Forrest N White BS1, Daniel C Zedek MD2, David L Collins DO3, J Scott Boswell MD3
Dermatology Online Journal 18 (3): 7

1. Columbia University College of Physicians and Surgeons, New York, New York
2. University of North Carolina, Chapel Hill, North Carolina
3. University of California San Francisco-Fresno, Fresno, California


Granuloma annulare (GA) is a reactive process in the dermis, related to degeneration of collagen. It may occur as an idiopathic phenomenon or in conjunction with a myriad of systemic conditions, including infectious disease. We report an interesting case of GA precipitated by pulmonary coccidioidomycosis.

Case report

A 48-year-old female presented to our clinic for evaluation of subtle erythematous nodules on her dorsal feet that arose in conjunction with persistent fevers, cough, and headache. Skin examination revealed several hyperpigmented subcutaneous annular nodules on the dorsum of the right foot and the dorsum of the left metatarsophalangeal joint.

Figure 1Figure 2
Figure 1. A 4 mm punch biopsy of the right dorsal foot nodule demonstrated an interstitial pattern of granuloma annulare with an infiltrate of histiocytes between collagen bundles.

2. A CT of her chest showed a 1.3 cm x 1.5 cm x 1.6 cm smooth pulmonary nodule in her left lower lobe.

Figure 3Figure 4

At presentation, immunodiffusion was positive for IgM antibodies against coccidiomycosis (with negative IgG), which 3 months later revealed positivity for IgG antibodies. Cerebrospinal fluid examination after lumbar puncture was negative for coccidioidomycosis antibodies.

With a diagnosis of pulmonary coccidioidomycosis, a 3-month course of fluconazole 400 mg/d was initiated, during which time her fevers, cough, and headaches resolved. The skin nodules’ erythema and size also decreased, leaving behind several hyperpigmented non-painful patches. The patient declined intralesional triamcinolone because the patches became asymptomatic for her. A follow up CT scan 15 months after initiation of therapy showed decreased size (1.0 cm x 1.2 cm x 1.0 cm) of the left lower lobe pulmonary nodule.


Granuloma annulare is a relatively common condition in which raised, erythematous lesions form in ring-like patterns, most commonly on the hands or feet. Although some patients experience mild pruritis, most cases are asymptomatic beyond the appearance of the lesions. Granuloma annulare usually resolves spontaneously in a few months to a few years; topical or intralesional corticosteroids have been used to successfully treat the condition.

The etiology of GA is not well understood, but it has been associated with several conditions including type I diabetes mellitus and other systemic diseases [1]. Cases have been reported in association with malignancy, trauma such as insect bites and tuberculosis tests, sun exposure, and viral infections including HIV, EBV, and VZV [2, 3]. The presence of activated T cells in the lymphocytic infiltrate has been demonstrated, suggesting that GA represents a cell-mediated immune response to a precipitating factor [4]. Whereas granulomatous interstitial dermatitis has also been reported to occur with pulmonary coccidioidomycosis, our case showed extensive mucin desposition without a heavy infiltrate of neutrophils and eosinophils, confirming a diagnosis of interstitial GA over this other entity [5]. Interestingly, our patient’s GA lesions arose in association with pulmonary coccidioidomycosis, a fungal infection endemic to California’s San Joaquin Valley, and improved as her coccidioidomycosis was treated.


1. Studer EM, Calza AM, Saurat JH. Precipitating factors and associated diseases in 84 patients with granuloma annulare: a retrospective study. Dermatology. 1996;193:364-8. [PubMed]

2. Li A, Hogan DJ, Sanusi ID, Smoller BR. Granuloma annulare and malignant neoplasms. Am J Dermatopathol. 2003;25:113-6. [PubMed]

3. Smith MD, Downie JB, DiCostanzo D. Granuloma annulare. Int J Dermatol. 1997;36:326-33. [PubMed]

4. Yun JH, Lee JY, Kim MK, Seo YJ, Kim MH, Cho KH, et al. Clinical and pathological features of generalized granuloma annulare with their correlation: a retrospective multicenter study in Korea. Ann Dermatol. 2009 May;21(2):113-9. [PubMed]

5. DiCaudo DJ, and Connolly SM: Interstitial Granulomatous Dermatitis Associated With Pulmonary Coccidioidomycosis. JAAD 45:840-5, 2001. [PubMed]

© 2012 Dermatology Online Journal