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Role for trauma in inducing pencil “lead” granuloma in the skin

2010; Elsevier BV; Volume: 62; Issue: 6 Linguagem: Inglês

10.1016/j.jaad.2009.02.027

1097-6787

Rachel H. Gormley, Stephen J. Kovach, Paul J. Zhang,

Traumatic Ocular and Foreign Body Injuries

To the Editor: Retained pencil “lead” may cause delayed foreign body granulomatous reactions in the skin.1Granick M.S. Erickson E.R. Solomon M.P. Pencil-core granuloma.Plast Reconstr Surg. 1992; 89: 136-138PubMed Google Scholar Pencil lead is actually made of graphite (66%), clay (26%), and wax (8%), each of which can induce a tissue reaction.1Granick M.S. Erickson E.R. Solomon M.P. Pencil-core granuloma.Plast Reconstr Surg. 1992; 89: 136-138PubMed Google Scholar The clay component, for instance, may contain silica, which is an agent known to cause delayed granulomatous reactions.1Granick M.S. Erickson E.R. Solomon M.P. Pencil-core granuloma.Plast Reconstr Surg. 1992; 89: 136-138PubMed Google Scholar The clinical and histologic appearance of these lesions can closely resemble malignant processes, especially melanoma, and therefore pencil lead granuloma should be included in the differential diagnosis of enlarging pigmented lesions. Five cases have previously been reported in the skin.1Granick M.S. Erickson E.R. Solomon M.P. Pencil-core granuloma.Plast Reconstr Surg. 1992; 89: 136-138PubMed Google Scholar, 2Hatano Y. Asada Y. Komada S. Fujiwara S. Takayasu S. A case of pencil core granuloma with an unusual temporal profile.Dermatology. 2000; 201: 151-153Crossref PubMed Scopus (16) Google Scholar, 3Taylor B. Frumkin A. Pitha J.V. Delayed reaction to “lead” pencil simulating melanoma.Cutis. 1988; 42: 199-201PubMed Google Scholar, 4Terasawa N. Kishimoto S. Kibe Y. Takenaka H. Yasuno H. Graphite foreign body granuloma.Br J Dermatol. 1999; 141: 774-776Crossref PubMed Scopus (29) Google Scholar, 5Yoshitatsu S. Takagi T. A case of giant pencil-core granuloma.J Dermatol. 2000; 27: 329-332PubMed Google Scholar Here we report a case occurring in the skin of the forehead. A 46-year-old man presented for evaluation of a bluish, progressively enlarging, painful mass on the forehead. He recalled having been impaled with a pencil by his younger brother when he was 5 years old, leaving a stable, asymptomatic, bluish macule at the site. A few months before he presented to our department, the patient hit his head on a door, sustaining moderate trauma to the site, with subsequent tenderness and enlargement of a soft tissue mass. The mass was surgically resected. Microscopically, the lesion was composed of multinodular growth within the dermis of nonnecrotizing granulomas associated with numerous dark pigmented granules (Fig 1). The black granular particulate material varied from very fine to up to 0.2 mm in size. Some of the finest particulate matter was seen within macrophages and giant cells. In the center of this florid granulomatous inflammation, there was a paucicellular hyalinized scar within which larger fragments of the black matter were embedded with no associated inflammatory reaction. Grocott and acid-fast stains were negative for fungal organisms and acid-fast bacilli. Stains were also negative for S100, pancytokeratin, and CD1a, ruling out a melanocytic, Langerhans cell, or epithelial lesion. Curiously, all reported cases of pencil lead granulomas present years after the initial injury, ranging from 9 to 58 years1Granick M.S. Erickson E.R. Solomon M.P. Pencil-core granuloma.Plast Reconstr Surg. 1992; 89: 136-138PubMed Google Scholar, 2Hatano Y. Asada Y. Komada S. Fujiwara S. Takayasu S. A case of pencil core granuloma with an unusual temporal profile.Dermatology. 2000; 201: 151-153Crossref PubMed Scopus (16) Google Scholar, 3Taylor B. Frumkin A. Pitha J.V. Delayed reaction to “lead” pencil simulating melanoma.Cutis. 1988; 42: 199-201PubMed Google Scholar, 4Terasawa N. Kishimoto S. Kibe Y. Takenaka H. Yasuno H. Graphite foreign body granuloma.Br J Dermatol. 1999; 141: 774-776Crossref PubMed Scopus (29) Google Scholar, 5Yoshitatsu S. Takagi T. A case of giant pencil-core granuloma.J Dermatol. 2000; 27: 329-332PubMed Google Scholar—40 years in this case. Such delayed reaction may be clinically alarming and may lead to the inflammatory process being confused with a neoplastic process, most commonly malignant melanoma.1Granick M.S. Erickson E.R. Solomon M.P. Pencil-core granuloma.Plast Reconstr Surg. 1992; 89: 136-138PubMed Google Scholar, 2Hatano Y. Asada Y. Komada S. Fujiwara S. Takayasu S. A case of pencil core granuloma with an unusual temporal profile.Dermatology. 2000; 201: 151-153Crossref PubMed Scopus (16) Google Scholar, 3Taylor B. Frumkin A. Pitha J.V. Delayed reaction to “lead” pencil simulating melanoma.Cutis. 1988; 42: 199-201PubMed Google Scholar, 4Terasawa N. Kishimoto S. Kibe Y. Takenaka H. Yasuno H. Graphite foreign body granuloma.Br J Dermatol. 1999; 141: 774-776Crossref PubMed Scopus (29) Google Scholar It has been suggested that this lag period preceding a rapid growth phase might correspond to the time required for the breakdown of graphite to a critical size, with dispersal to the interstitum.2Hatano Y. Asada Y. Komada S. Fujiwara S. Takayasu S. A case of pencil core granuloma with an unusual temporal profile.Dermatology. 2000; 201: 151-153Crossref PubMed Scopus (16) Google Scholar In our patient, the clinical history suggests a role for trauma in the mechanical breakdown and dispersal of particles to a degree necessary for activation and induction of granulomatous inflammation, with subsequent rapid growth and pain. In conclusion, this case confirms the delayed nature of granulomatous foreign body reactions in response to retained pencil lead, and shows that in addition to melanin and tattoo, pencil tip injury should be considered when dark granular pigment is present in cutaneous tissue with or without granulomatous inflammation.