Letters to the Editor the location that had not been reported before. An was diagnosed as extraskeletal chondroma based on its excisional biopsy was performed without imaging typical histological pattern without atypia, mitosis or studies, such as X‑rays, computed tomography, and prominent stromal degeneration. ultrasonography as the patient refused to take further studies. During surgery, we confirmed that the nodule Complete excision is recommended for the treatment was not attached to the underlying skull, and the of extraskeletal chondroma. It is generally considered mass located in the subcutaneous layer was easily that extraskeletal chondroma is not likely to show excised. Histopathologic examination revealed an malignant transformation,[4] because malignant change encapsulated nodule that was entirely composed of is extremely rare. We have experienced an interesting mature cartilage [Figure 1b]. Chondrocytes in lacunae case of extraskeletal chondroma that occurred in an had oblong nuclei of various size [Figure 1c]. There atypical site. To the best of our knowledge, this is the were no cytologic atypia, mitosis or necrosis. Based first case report that was found in the scalp. on the characteristic histopathologic features, the patient was diagnosed with extraskeletal chondroma Yunseok Choi, Won‑Suk Lim, Ai‑Young Lee, of the scalp, and there were no signs of recurrence at Seung‑Ho Lee 6 months from the excision. Department of Dermatology, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang, South Korea

Extraskeletal chondroma is a rare, benign cartilaginous Address for correspondence: Dr.Seung‑Ho Lee, tumor of the soft tissue. It presents as a solitary Department of Dermatology, Dongguk University Ilsan Hospital, subcutaneous nodule or mass measuring less than College of Medicine, Dongguk University, 814 Siksa‑Dong, 3 cm in diameter that is usually painless and slowly Ilsandong‑gu, Goyang‑si, Gyeonggi‑do, South Korea. E‑mail: [email protected] growing.[1] It is most frequently found in the hands and feet of adults in the fourth and fifth decades.[1] The REFERENCES majority has no symptoms, but Chung and Enzinger[1] reported that 19% of patients had pain and tenderness. 1. Chung EB, Enzinger FM. Chondroma of soft parts. Cancer 1978;41:1414‑24. Although the etiology of soft tissue chondroma is 2. Falleti J, De Cecio R, Mentone A, Lamberti V, Friscia M, De not completely known, it is believed that they arise Biasi S, et al. Extraskeletal chondroma of the masseter muscle: A case report with review of the literature. Int J Oral Maxillofac from residual embryonic tissue or from uncommitted Surg 2009;38:895‑9. mesenchymal stem cells by either metaplastic or 3. Kwon H, Kim HY, Jung SN, Shon WI, Yoo G. Extraskeletal neoplastic process.[2] chondroma in the auricle. J Craniofac Surg 2010;21:1990‑1. 4. Weiss SW, Goldblum JR. Cartilaginous soft tissue tumors. In: Weiss SW, Goldblum JR, Enzinger FM, editors. Enzinger Histologically it shows an encapsulated lobular nodule and Weiss’s soft tissue tumors. 4th ed. St Louis: Mosby; 2001. p. 1361‑8. composed of mature hyaline cartilage, and is not 5. Lee JW, Kim DS, Kim MK, Suh YL. Chondroblastoma‑like associated with underlying bone tissues.[1] However, it extraskeletal chondroma. Korean J Pathol 1999;33:55‑8. may show foci of dystrophic calcification or metaplastic Access this article online ossification. Occasionally, nuclear atypia, pleomorphism, binucleated lacunae, or stromal myxoid degeneration Quick Response Code: Website: www.ijdvl.com are found. Our case revealed an encapsulated nodule of mature cartilage with no cytologic atypia or mitosis. DOI: Although it can be easily diagnosed based on its 10.4103/0378-6323.110793 typical histological findings, tumoral calcinosis, giant PMID: cell tumor, chondroblastoma and chondrosarcoma ***** are included in the differential diagnosis. Tumoral calcinosis should be differentiated when calcification in the tumor is prominent. Cartilaginous tissues are not present and foreign body reaction is associated with Unusual presentation of lichen tumoral calcinosis.[4] Giant cell tumor may be considered when granulomatous change is present, but it does not scrofulosorum contain chondrocytes in the tumor.[4] Chondroblastoma should be differentiated when tumor cells resemble chondroblasts that were not found in our case.[5] Sir, Chondrosarcoma presents mitosis, atypism, and necrosis An 8‑year‑old girl presented with complaints of mildly that are not seen in extraskeletal chondroma.[1] Our case itchy red‑colored tiny lesions over the trunk since

436 Indian Journal of Dermatology, Venereology, and Leprology | May-June 2013 | Vol 79 | Issue 3 Letters to the Editor

3 months. The patient denied any history of fever, cold done which revealed normal epidermis and infiltrate and cough, scaling over scalp and extensor aspects, or in upper dermis and around hair follicles forming any history of palmoplantar keratoderma. Cutaneous granulomas with lymphohistiocytic infiltrate and examination revealed multiple erythematous papules giant cells [Figures 2 and 3]. A diagnosis of lichen of 1‑2 mm in size arranged in an annular pattern forming scrofulosorum (LS) was made. High‑resolution 3‑5 cm plaques associated with mild scaling. The computerized tomography (CT) scan of chest lesions were distributed over the trunk, arms, thighs, showed adjacent to aortic arch, and pre‑auricular region [Figure 1]. She was treated aortopulmonary (AP) window left hilar, subcarinal, with oral anti‑histamines and topical emollients. Bacille and left bronchopulmonary regions along with patchy calmette‑guérin (BCG) vaccination scar was visible on consolidation in left inferior lingual lobe. CT scan of the left deltoid area. Differential diagnosis of follicular abdomen showed a calcified splenic granuloma with psoriasis, pityriasis rubra pilaris, pityriasis rosea, mild hepatosplenomegaly. Skin tissue was sent for and atopic dermatitis were made. Her hemoglobin (TB) polymerase chain reaction (PCR) was level was 10 g%, Erythrocyte sedimentation rate was positive for 123 base pairs (in II amplification round), 50 mm and Mantoux test was 20 mm with blistering. consistent with positive tuberculosis Chest X‑ray and ultrasonography of abdomen infection. The patient was started on isoniazid, revealed no abnormality. Human immunodeficiency 225 mg; rifampicin, 225 mg; pyrazinamide, 750 mg; virus antibodies test and venereal disease research and ethambutol, 600 mg. Excellent response was noted laboratory test were non‑reactive. Skin biopsy was in 6 weeks in the form of complete subsidence of the lesions with post‑inflammatory hyperpigmentation and scaling [Figure 4].

Figure 1: Multiple erythematous 2 mm‑sized papules arranged in an annular pattern forming 3‑5 cm plaques associated with mild scaling over the trunk Figure 2: H and E staining of a skin biopsy showing granulomatous infiltrate around hair follicle (×100)

Figure 3: H and E staining of a skin biopsy showing granulomas with lymphohistiocytic infiltrate and giant cells (×400) Figure 4: After treatment photographs of the patient

Indian Journal of Dermatology, Venereology, and Leprology | May-June 2013 | Vol 79 | Issue 3 437 Letters to the Editor

Tuberculides are explained to be a hypersensitivity revealed involvement of multiple lymph nodes, lung, reaction to M. tuberculosis or its products in a liver, and spleen. We also detected M. tuberculosis patient with significant immunity.[1] LS is a lichenoid by PCR in biopsy specimen of LS in our patient. eruption of minute papules ascribed to hematogenous Although in the experience of Tan, et al., polymerase spread of mycobacteria in an individual with strong chain reaction (PCR) has not been found to be a useful anti‑tuberculous cell‑mediated immunity. It is usually complement for clinical and histological diagnoses of associated with strongly positive tuberculin reaction.[1] “paucibacillary” forms of cutaneous TB.[4] Padmavathy It has also been observed after BCG vaccination and in et al. reported a case of PCR positivity in LS.[5] This association with Mycobacterium avium‑intracellulare report and our case supports the concept of tuberculids infections. as immunological reactions to degenerate dead bacilli or antigenic fragments thereof that have been deposited LS is found to the second most common form of in skin and the subcutis.[6] To conclude, such extensive cutaneous TB, according to recent reports, possibly inflammatory form of LS, which is exceedingly rare, because of increased incidence of all types of should prompt clinicians to search for underlying tuberculous infection. Seven percent of cutaneous TB disseminated internal tuberculous involvement. patients were found to have LS in a prospective study in India in 2005. More than 80% cases affected are Ameet Dandale, Nandini Gupta, [1] younger than 16 years of age. Rachita Dhurat, Smita Ghate Department of Dermatology, LTM Medical College, The lesions usually present over trunk as symptomless Sion, Mumbai, India clusters of firm, typically perifollicular, pink or yellow brown papules of 0.5‑3 mm topped by a scale. Lesions Address for correspondence: Dr. Ameet Dandale, Department of Dermatology, LTM Medical College, persist for months and then spontaneously involute Sion, Mumbai, India. without scarring. Micropustular and noduloulcerative E‑mail: [email protected] variants have been described.[2] Lesions may coalesce REFERENCES to form annular or discoid plaques.[2] Our case presented with extensive, inflammatory, and scaly 1. Yates VM. Mycobacterial Infections. In: Burns T, Breathnach S, plaques resembling psoriasis. Though there is a report Cox N, Griffith C, editors. Rook’s Textbook of Dermatology. th of psoriasiform LS dating back to 1911,[2] very few 8 ed. Massachusettes: Wiley‑Blackwell; 2010. p. 31.21‑22. 2. Weber FP. Lichen scrofulosorum imitating psoriasis. Proc R Soc [3] cases of this entity have been reported. Med 1911;4:93. 3. Kumar U, Sethuraman G, Verma P, Das P, Sharma VK. Differential diagnosis includes follicular lichen planus, Psoriasiform type of lichen scrofulosorum: Clue to disseminated tuberculosis. Pediatr Dermatol 2011;28:532‑4. lichen nitidus, secondary , lichen spinulosus, 4. Tan SH, Tan BH, Goh CL, Tan KC, Tan MF, Ng WC, et al. keratosis pilaris, sarcoidosis, drug eruptions, and Detection of Mycobacterium tuberculosis DNA using polymerase dermatophytid reactions. Histological examination chain reaction in cutaneous tuberculosis and tuberculids. Int J Dermatol 1999;38:122‑7. demonstrates superficial non‑caseating granulomas 5. Padmavathy L, Rao L, Veliath A. Utility of polymerase chain around hair follicles and sweat ducts. Mycobacteria reaction as a diagnostic tool in cutaneous tuberculosis. Indian J are not seen and not be cultured from biopsy material. Dermatol Venereol Leprol 2003;69:214‑6. 6. Lucas S. Bacterial diseases. In: Lever WF, Schaumberg Lever G, Specific anti‑tuberculous therapy produces complete editors. Histopathology of the Skin. 10th ed. Philadelphia: JB clearance within 4‑8 weeks without scarring.[1] Lippincott; 2009. p. 554.

Access this article online Main association of LS has been found to be with Quick Response Code: tuberculous lymph nodes followed by foci in bone. LS Website: www.ijdvl.com can also be associated with other types of cutaneous TB such as , , and DOI: 10.4103/0378-6323.110797 .[1] Our patient had no systemic complaints and presented only with skin lesions with PMID: ***** mild itching. However, search for internal focus of TB

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