Disseminated granuloma annulare and hepatocellular carcinoma: association or coincidence?

To cite: Mestre T, Rodrigues AM, Cardoso J. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2014-205883 DESCRIPTION Granuloma annulare is a granulomatous skin disease of unknown aetiology. It is more common in women and has a disseminated form in 10–15% of patients. A small portion of these patients have an associated disease such as diabetes mellitus, viral infection, vaccine reaction or cancer. Haematological neoplasms and adenocarcinomas are those most frequently found. The authors present the case of 68-year-old man with a recent diagnosis of hepatocellular carcinoma (figure 1). Simultaneously with the diagnosis, he referred to the appearance of more than 10 infiltrated erythematous plaques, smooth surfaced and annular shaped (figure 2). Cutaneous histopathological examination of these lesions showed a lymphohistiocytic infiltrate with multinucleated giant cells in a palisade pattern in the papillary and reticular dermis and some foci of granulomatous reaction surrounding foci of altered collagen. This was compatible with the diagnosis of granuloma annulare (figure 3). The patient was treated with topical dipropionate of β methasone twice daily with a slight improvement of the dermatosis. Palliative treatment with chemoembolisation was offered to the patient, but he died some months later. The pathogenesis of granuloma annulare is unknown. In the cases linked to cancer there is evidence suggesting that the mechanism of pathogenesis is related to a type 1 T helper (Th-1 type) delayed hypersensitivity cross-reaction, in which the tumour antigens act as triggers of the dermatosis. The temporal relationship between the diagnosis of the neoplasia and granuloma annulare is variable; it may appear before, during or after the first diagnosis (18 months to 7 years). Haematological neoplasms are the most frequently