Differential diagnosis of pseudorheumatoid nodules of the eyelid (granuloma annulare, nodular type)

Patient A 51-year-old male presented with multiple subcutaneous nodules in both upper eyelids. An excisional biopsy and blepharoplasty were performed. Histopathologically, centrally located acellular necrotic areas of collagen fibers were surrounded by fibroblasts, epitheloid cells and giant cells. Special stains including Gram, Warthin-Starry, Gomori-methenamine silver and Ziehl-Neelsen revealed no evidence of infectious microorganisms. The eyes were otherwise unremarkable. The patient was in good health. He did not show any evidence of rheumatoid arthritis, rheumatic fever or other systemic disease. Results: of laboratory studies for rheumatoid factor, antinuclear antibodies, angiotensin converting enzyme, VDRL, FTA-ABS, antistreptolysin-O, erythrocyte sedimentation rate and immunoelectrophoresis were within normal limits. Based on the negative evaluation for systemic disease and the histopathologic appearance of the lesions, we made the diagnosis of pseudorheumatoid nodules (granuloma anulare, nodular type). Conclusion: Pseudorheumatoid nodules are subcutaneous tenderless tumors which usually occur in children and young adults, but also in older patients. Histopathologically similar granulomas may be observed in patients with various systemic diseases such as rheumatoid arthritis, rheumatic fever and systemic lupus erythematosus. Excisional biopsy, histopathologic examination and evaluation for systemic disease are important in the differential diagnosis of pseudorheumatoid nodules involving episclera, conjunctiva and ocular adnexa.