Photodermatitis in a 57-year-old man

presented by David Elpern MD (1) and Jag Bhawan MD (2)

(1) Williamstown, MA, USA

(2) Boston, MA, USA

on July 25, 2004

(1) Dermatologist, The Skin Clinic, Williamstown, MA, USA

(2) Professor of Dermatology and Pathology, Boston University School of Medicine, Boston, Massachusetts, USA

 
Patient
W.P. 57-year-old white male
Duration
2 months
Distribution
Face and neck
History

W.P. was first seen on June 18, 2004. This 57 yo business consultant had developed a dermatitis in the early May of 2004. He has an outdoor lifestyle. He is in good general health other than insulin dependent diabetes. His medications included lisinopril (discontinued after office visit), Lipitor (atorvastin) and insulin.
Physical Examination

Showed an erythematous eruption on the V of the neck, posterier neck and extensor aspects of the arms. The mid-line submental area was spared. The primary lesions were discreet and confluent erythematous papules. By July 1, in spite of topical therapy his lesions had progressed to involve his cheeks.
Images

Laboratory Data

CBC - normal.

Chemistries normal.

ANA panel negative. Anti-Histone antibodies negative.
Histopathology

Fig 1 Palisading histocytic granuloma with moderate perivascular lymphoid cell infiltrate. 10x

Fig. 2 Interstitial histocytes and many multinucleate giant cells are easily seen. Note elastophagocytosis (arrow). 20x

Fig. 3 Elastophagocytosis in a giant cell multinucleate giant cell (arrow). 40x

Interstitial histiocytic infiltrate with palisading granulomatous dermatitis with elastophagocytosis. This was consistent with granuloma annulare. Actinic granuloma is in the differential diagnosis.
Diagnosis

Actinic granuloma: a photodermatitis.
Reasons Presented

For your thoughts about this case

Questions W.P. eruption has not changed significantly in spite of switching his antihypertensive, using wet compresses and a moderate-strength topical corticosteroid cream.

On July 16th, 2004 the patient contacted me and related that he had started drinking tonic water (quinine) at around the onset of the eruption. Good detective work on his part.

This has not been reported with quinine or as a drug reaction in the literature; but the possibility exists that it was related to a medication or the
tonic water. The latter has been stopped and he will continue on topical therapy. Your thoughts and suggestions will be appreciated.
References Limas C. The spectrum of primary cutaneous elastolytic granulomas and their distinction from granuloma annulare: a clinicopathological analysis. Histopathology. 2004 Mar;44(3):277-82.

Lim DS, Triscott J. O'Brien's actinic granuloma in association with prolonged doxycycline phototoxicity. Australas J Dermatol. 2003 Feb;44(1):67-70.

Comments from Faculty and Members

Jerry Litt MD, Beachwood, Ohio on July 26, 2004

In my DRUG ERUPTION REFERENCE MANUAL, Tenth Edition, 2004, there are listed twenty (20) references reporting QUININE to cause photosensitivity.

Julian Manzur MD, Havana, Cuba on July 26, 2004

Beautiful digital images showing the histologic features. I agree with the opinion that actinic granuloma should be distinguished from granuloma annulare and is an independent condition.

Massone Cesare MD, Graz, Austria on Sept 4, 2004

Remarcable case that shows the difference between actinic granuloma and granuloma anulare on sun damaged-skin. However, maybe these two entities belongs to two ends of a spectrum: actinic granuloma and AEGCG on one side and elastophagocytosis accompanying other diseases on the other side.