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Unusual silica granulomas of the skin with massive involvement of axillary lymph nodes
Path. Res. Pract. 164, 198- 206 (1979)
Rare and Unusual Cases
Department of Pathology, City Hospital, Leverkusen, and Department of Applied Physics, Bayer AG, Leverkusen, West Germany
Unusual Silica Granulomas of the Skin with Massive Involvement of Axillary Lymph Nodes K. KOCHEMANN and R. HOLM
Summary Silica granulomas are rare in the skin. Involvement of the regional lymph nodes seems to be unusual. The case of a 35-year-old man with massive diffuse fibrosis of the axilla with multiple foreign body granulomas and involvement of axillary lymph nodes is presented. The lymph nodes exhibit multiple epithelioid cell granulomas and silicotic nodules which are indistinguishable from similar nodules in mediastinal lymph nodes in pulmonary silicosis. It is assumed that the numerous silica particles which were identified by X-ray microanalysis under the scanning electron microscope and recovered from the mineral ash after incineration were accidentally implanted into the skin at the time of an injury 26 years previously. The long delay between silica exposure and granuloma development is a typical feature of these lesions. The possible mechanisms operative in this process are discussed.
Introduction Silica granulomas are well known though relatively rare in the skin. It is puzzling that these lesions are not seen more frequently although silica (silicon dioxide, quartz) is a frequent compound in our environment. For instance, silica is often deposited in the form of glass particles in skin wounds after automobile accidents. However, silica may be derived from many other sources. Miners drilling into silica-bearing rocks may inhale silica dust or rarely produce a foreign body reaction after accidental implantation of silica into skin wounds. There are other industries or occupations with specific hazards (production of quartz glass or ceramics, rubber production, construction, sandblasting, extermination, scouring and cleaning etc.), Gravel, granite, cement, flint, slate and many other compounds contain silica. Free pulverized quartz is frequently encountered in
Unusual Silica Granulomas of the Skin . 199
detergents and powders due to its white color. The potential danger of such admixtures seems to be widely underestimated. This paper is not concerned with pulmonary silicosis but only deals with silica granulomas of the skin and lymph nodes. Because the average practicing pathologist who encounters a foreign body granuloma with doubly refractile crystalline material is rarely trained in its exact identification (see Johnson, 1972), some silica granulomas may not be recognized as such. However, it still appears that they are much rarer than would be expected from the frequency of silica deposition in skin wounds (Knight, 1962; Rank et al., 1972). In addition, there is usually a long interval between tissue exposure to silica and granuloma development (Degos and Civatte, 1959: several weeks to 56 years; Rank et al., 1972: 2 to 50 years; Shelley and Hurley, 1960: 10 years representative average). A history of adequate exposure to a specific agent is therefore frequently not available. Granulomas are usually limited to the skin and subcutaneous fat tissue, while involvement of lymph nodes seems to be unusual. In their excellent and comprehensive paper on this subject Shelley and Hurley (1960) noted that "the regional lymph nodes may also be enlarged", because "at least some of the silica reaches the local lymph nodes". According to these authors, "the regional lymph nodes may show an epithelioid granuloma replacing the lymphoid tissue". This report describes a case with diffuse silicotic fibrosis of the axilla and massive involvement of axillary lymph nodes. A similar case was not found by us in the literature.
Case Report A 35-year-old man presented to the hospital (St.-]osef-Krankenhaus, Leverkusen) on December 30, 1974, with a several week history of swelling of the right axilla where a large irregular firm mass was felt. He had had an operation at this site 26 years previously at the age of 9 in East Germany (DDR) where he was hospitalized for 3 months but does not remember why. The mass was nonencapsulated and closely adherent to surrounding structures. Several pieces of removed tissue had a dense scar-like consistency on gross examination. Histologically very dense, focally calcified scar tissue was found (Fig. I). Scattered necroses were surrounded by nonspecific granulation tissue with multiple epithelioid cell granulomas and numerous foreign body giant cells. Under polarized light a large number of doubly refractile crystalline particles greatly varying in size and shape
200 .
K. Kiichemann and R. Holm
Fig. 1. Very dense diffuse scar tissue with foreign body giant cells (inset upper right) and abundant doubly refractile crystalline material (inset upper left). H&E; X 75 (inset upper right: X 195).
were evident (Fig. I, inset upper left). The diagnosis was old foreign body granuloma. The patient returned to the hospital 1 1/2 months later when a recurrent plum-sized mass was removed. Again it had a very dense "woody" consistency and abundant doubly refractile crystalline material was found under polarized light within scar tissue containing foreign body granulomas. The mass was poorly circumscribed and the surgeon felt he could not completely remove it. A third operation was performed 2 1/2 years later when several cherry-sized pieces of scar tissue containing foreign body granulomas and numerous doubly refractile particles were removed. Due to the recurrent nature of the lesion the surgeon finally felt he was dealing with a tumor. 5 months after the third operation the patient again returned to the hospital. At this time three together orange-sized pieces of tissue weiging 35 g were excised together with a 4 X I em piece of skin. The fibrosis had encroached upon the large axillary blood vessels. As of now the "tumor" has recurred again but further surgery has not been done because the surgeon fears to run the risk of injury to the great vessels. The tissue cut with gritty consistency and was grayish-yellow. Several large lymph nodes were also included showing multiple foci of yellowish necroses. On histological examination the lymph nodes display diffusely distributed epithelioid cell granulomas (Fig. 3) with occasional giant cells.
Unusual Silica Granulomas of the Skin
.
201
Fig. 2 . Multiple sharply demarcated silicot ic nodules with concentric arrangement of dense collagen fibers in axillary lymph node . Path. Inst. Lev. E.-Nr. 1484/78; H & E; X 30.
Fig. 3. Silicotic nodule exhibiting central necrosis with focal calcification (arrow) and multiple epithelioid cell gran ulomas in axillary lymph node. H&E ; X 75.
202 .
K. Kiichemann and R. Holm
In addition multiple characteristic sharply delimited silicotic nodules with concentrically arranged dense collagen fibers and central necroses with occasional calcifications are seen (Fig. 2, 3)' These changes do not differ from those seen in hilar lymph nodes in pulmonary silicosis. There are thousands of polygonal doubly refractile foreign bodies particulary within the diffuse scar and granulation tissue. They are found in smaller numbers mostly in the periphery of the silicotic nodules many of them being completely free of demonstrable foreign material. Some of the silicotic nodules are completely calcified. After preparation of paraplast blocks for light microscopy, a piece of tissue was studied with the scanning electron microscope at 30 kV (Fig. 4, 5). The sample which had been fixed in sodium phosphate-buffered neutral formalin was air dried and coated with carbon. This preparation technic allows the combination of imaging and microanalysis by means of an energy dispersive X-ray spectrometer. The X-ray spectrum of the fixed tissue containing the crystals reveals the silicon content in addition to other com-
Fig. 4. Scanning electron micrograph of scar tissue with polygonal quartz crystals (largest crystal in center of picture). X 200.
Unusual Silica Granulomas of the Skin .
203
ponents derived from the tissue and the buffer (Fig. 6 a). When the electron beam was focused on one of the crystals, e.g. the one depicted in Figure 5, the spectrum shown in Figure 6 b was obtained which only exhibits the element silicon and is identical with the spectrum of the residual particles after incineration (Fig. 6 c) and of isolated crystals from scouring powders such as ATA (Fig. 6 d). The energy dispersive X-ray spectra do not indicate the light elements with atomic numbers < 9, in this case the oxygen. To be sure that the particles were SiO~ in the form of crystalline quartz and not glass, the remainder of the tissue was incinerated. 0.6 g white powder were recovered from this residue of onl y one biopsy. The Debeye-Scherrer pattern of an X-ray diffraction of this powder definitely revealed coarse crystalline quartz. In summary, the crystalline doubly refractile material which is responsible for the foreign body reaction and the production of silicotic nodules in the axillary lymph nodes consists of pure SiO~ (quartz).
Fig. 5. Scanning electron micrograph of isolated quartz crystal at higher magnification. X 5,900.
204 .
K. Kiichemann and R. Holm p
Q.
b.
c.
d.
1,7 2,3 3,4
IT
Fig. 6. Ener gy dispersive X- ray spectr a obta ined und er the scanning electron microscope. Abscissa: energy of x-rays , (a) Tissue fixed in buffered neutral formalin and containing quartz crystals (buffer contains sodium phosphate) . Note silicon peak. (b) Isolated quartz cry stal (see Fig. 5). (c) Residue after incinerat ion. (d) Isolated crystal from ATA (Ge rman scourin g powder) for comparison.
Discussion The case presented her e exhibits the characteristic features of silica granulomas. It must be assumed that the surgery done 26 years previously at the site of th e present lesion has someho w to do with the accidental implantation of silica. The long hospitalization (3 months) ma y indicate a severe injury treated at th at time, but unfortunately a precise history of adequate exposure to a specific agent is not available. The sudden rapid and recurrent appearance of granulomas after 26 years is a typical feature of these lesions as is indicated above. However, the large amount of silica present and the site and extent of the lesion w ith final compromise of the large ax illary blood vessels seem to be very unusual. In addition, the involvement of lymph nodes with multiple silicot ic nodules has not been described previously in skin lesions. It is not the purpose of this report to clarify the long delay of granuloma de velopment . Several th eories have been advanced. V isible silica particles are in the ra nge of I to 1 0 0 11m (Fig. 4, 5). Such large particles
Unusual Silica Granulomas of the Skin .
205
apparently do not evoke a granulomatous reaction. According to Shelley and Hurley (1960) silica must be in a colloidal state in order to be able to elicit a typical granulomatous reaction. This "critical release of colloidal silica" which is due to "slow chemical weathering" may take many years and is thought to be the reason for the long delay between silica implantation and granuloma development in the skin. According to the above authors "the rate of reaction of the body to quartz is inversely proportional to the size of the particle". Other authors (Epstein, 1967; Rank et al., 1972) favor a granulomatous hypersensitivity reaction. According to Rank et al. (1972) "the pathological process occurring in silicon granuloma of the skin appears to be rather different from that in lung silicosis". In pulmonary silicosis, small silica particles are engulfed by macrophages and enclosed within intracellular phagosomes. The phagosomal membrane is disrupted by lysosomes leading to cell death. Dead macrophages induce the typical fibrogenic response. According to Rank et al. (1972) cutaneous silicosis is characterized by "an epithelioid response which is most characteristic of hypersensitivity ". The lymph nodes of our case do contain typical silicotic nodules as seen in pulmonary silicosis as well as diffuse epithelioid cell granulomas (Fig. 2, 3). Perhaps several mechanisms are operative in the development of silicainduced extrapulmonary lesions. The main primary difference between pulmonary and extrapulmonary silicosis is a matter of particle size. Particles in lung silicosis are in the range of I to 5 urn (average 2 urn). Large particles such as seen in skin lesions are usually removed from the lung before they reach the terminal air passages. However, just as in pulmonary silicosis, in the skin only the small particles seem to be significant in the development of silica granulomas. Whatever the mechanism, the large size of the original particles in our case precluded their entry into the lymphatic channels. After a long interval they must have finally been broken down to smaller particles which initially excited a local foreign body reaction in the skin. They were then probably picked up by macrophages and carried to regional lymph nodes where they elicited an epithelioid response that differs from the foreign body granulomas seen in the primary lesion of the skin. Such phagocytosis of particulate matter is known to be an important first step in the initiation of primary immune responses. The silicotic nodules, however, are in no way different from those found in mediastinal lymph nodes. This finding does not support the assumption of Rank et al. (1972) that the process leading to lung silicosis is in all respects rather different from that in skin silicosis.
206 . K. Kiichemann and R. Holm
Acknowledgments: We are grateful to Drs. L. van Beeck, Chief, Department of Surgery, and D. Kamp, St.-Josef-Krankenhaus Leverkusen, for permission to report the case of this patient under their care and for obtaining follow-up information for this study. We wish to express our appreciation to Dr. E. Scherz, Medical Service, Bayer AG, for his cooperation in this investigation. Dr. Born, Bayer AG, kindly provided the Debeye-Scherrer pattern of the mineral ash. We are indebted to Prof. H. Gartmann, Department of Dermatology, and Prof. R. Fischer, Chairman of the Department of Pathology, University of Cologne, for advice and discussions. We are also grateful to Prof. G. Pfefferkorn, Director of the Institute for Medical Physics, University of Miinstcr, for valuable suggestions.
References Degos, R., and Civatte, J.: Das Silikosegranulom der Haut. Hautarzt 10, 106-110 (1959) Epstein, W. L.: Granulomatous hypersensitivity. Progr. Allergy II, 38-88 (1967) Johnson, F. B.: Crystals in pathologic specimens. Path. Annu, 7, 321-344 (1972) Knight, C. R.: Silicon granuloma of skin: Case report. Brit. J. Plast. Surg. 15, 2I 3-2 15 (1962) Rank, B. K., Hicks, J. D., and Levie, M.: Pseudotuberculoma granulosum silicoticum. Brit. J. Plast, Surg. 25, 42-48 (1972) Shelley, W. B., and Hurley, J. H.: The pathogenesis of silica granulomas in man: a non-allergic colloidal phenomenon. J. invest. Derm. 34, 107-123 (1960)
Received August 10, 1978 . Accepted October 2, 1978
Key words: Silica granuloma - Foreign body granuloma - Epithelioid cell granuloma - Granuloma - Lymph nodes
Dr. Klaus Kiichemann, Pathologisches Institut des Stadtischen Krankenhauses, Dhiinnberg 60, D-5090 Leverkuscn I
Rare and Unusual Cases
Department of Pathology, City Hospital, Leverkusen, and Department of Applied Physics, Bayer AG, Leverkusen, West Germany
Unusual Silica Granulomas of the Skin with Massive Involvement of Axillary Lymph Nodes K. KOCHEMANN and R. HOLM
Summary Silica granulomas are rare in the skin. Involvement of the regional lymph nodes seems to be unusual. The case of a 35-year-old man with massive diffuse fibrosis of the axilla with multiple foreign body granulomas and involvement of axillary lymph nodes is presented. The lymph nodes exhibit multiple epithelioid cell granulomas and silicotic nodules which are indistinguishable from similar nodules in mediastinal lymph nodes in pulmonary silicosis. It is assumed that the numerous silica particles which were identified by X-ray microanalysis under the scanning electron microscope and recovered from the mineral ash after incineration were accidentally implanted into the skin at the time of an injury 26 years previously. The long delay between silica exposure and granuloma development is a typical feature of these lesions. The possible mechanisms operative in this process are discussed.
Introduction Silica granulomas are well known though relatively rare in the skin. It is puzzling that these lesions are not seen more frequently although silica (silicon dioxide, quartz) is a frequent compound in our environment. For instance, silica is often deposited in the form of glass particles in skin wounds after automobile accidents. However, silica may be derived from many other sources. Miners drilling into silica-bearing rocks may inhale silica dust or rarely produce a foreign body reaction after accidental implantation of silica into skin wounds. There are other industries or occupations with specific hazards (production of quartz glass or ceramics, rubber production, construction, sandblasting, extermination, scouring and cleaning etc.), Gravel, granite, cement, flint, slate and many other compounds contain silica. Free pulverized quartz is frequently encountered in
Unusual Silica Granulomas of the Skin . 199
detergents and powders due to its white color. The potential danger of such admixtures seems to be widely underestimated. This paper is not concerned with pulmonary silicosis but only deals with silica granulomas of the skin and lymph nodes. Because the average practicing pathologist who encounters a foreign body granuloma with doubly refractile crystalline material is rarely trained in its exact identification (see Johnson, 1972), some silica granulomas may not be recognized as such. However, it still appears that they are much rarer than would be expected from the frequency of silica deposition in skin wounds (Knight, 1962; Rank et al., 1972). In addition, there is usually a long interval between tissue exposure to silica and granuloma development (Degos and Civatte, 1959: several weeks to 56 years; Rank et al., 1972: 2 to 50 years; Shelley and Hurley, 1960: 10 years representative average). A history of adequate exposure to a specific agent is therefore frequently not available. Granulomas are usually limited to the skin and subcutaneous fat tissue, while involvement of lymph nodes seems to be unusual. In their excellent and comprehensive paper on this subject Shelley and Hurley (1960) noted that "the regional lymph nodes may also be enlarged", because "at least some of the silica reaches the local lymph nodes". According to these authors, "the regional lymph nodes may show an epithelioid granuloma replacing the lymphoid tissue". This report describes a case with diffuse silicotic fibrosis of the axilla and massive involvement of axillary lymph nodes. A similar case was not found by us in the literature.
Case Report A 35-year-old man presented to the hospital (St.-]osef-Krankenhaus, Leverkusen) on December 30, 1974, with a several week history of swelling of the right axilla where a large irregular firm mass was felt. He had had an operation at this site 26 years previously at the age of 9 in East Germany (DDR) where he was hospitalized for 3 months but does not remember why. The mass was nonencapsulated and closely adherent to surrounding structures. Several pieces of removed tissue had a dense scar-like consistency on gross examination. Histologically very dense, focally calcified scar tissue was found (Fig. I). Scattered necroses were surrounded by nonspecific granulation tissue with multiple epithelioid cell granulomas and numerous foreign body giant cells. Under polarized light a large number of doubly refractile crystalline particles greatly varying in size and shape
200 .
K. Kiichemann and R. Holm
Fig. 1. Very dense diffuse scar tissue with foreign body giant cells (inset upper right) and abundant doubly refractile crystalline material (inset upper left). H&E; X 75 (inset upper right: X 195).
were evident (Fig. I, inset upper left). The diagnosis was old foreign body granuloma. The patient returned to the hospital 1 1/2 months later when a recurrent plum-sized mass was removed. Again it had a very dense "woody" consistency and abundant doubly refractile crystalline material was found under polarized light within scar tissue containing foreign body granulomas. The mass was poorly circumscribed and the surgeon felt he could not completely remove it. A third operation was performed 2 1/2 years later when several cherry-sized pieces of scar tissue containing foreign body granulomas and numerous doubly refractile particles were removed. Due to the recurrent nature of the lesion the surgeon finally felt he was dealing with a tumor. 5 months after the third operation the patient again returned to the hospital. At this time three together orange-sized pieces of tissue weiging 35 g were excised together with a 4 X I em piece of skin. The fibrosis had encroached upon the large axillary blood vessels. As of now the "tumor" has recurred again but further surgery has not been done because the surgeon fears to run the risk of injury to the great vessels. The tissue cut with gritty consistency and was grayish-yellow. Several large lymph nodes were also included showing multiple foci of yellowish necroses. On histological examination the lymph nodes display diffusely distributed epithelioid cell granulomas (Fig. 3) with occasional giant cells.
Unusual Silica Granulomas of the Skin
.
201
Fig. 2 . Multiple sharply demarcated silicot ic nodules with concentric arrangement of dense collagen fibers in axillary lymph node . Path. Inst. Lev. E.-Nr. 1484/78; H & E; X 30.
Fig. 3. Silicotic nodule exhibiting central necrosis with focal calcification (arrow) and multiple epithelioid cell gran ulomas in axillary lymph node. H&E ; X 75.
202 .
K. Kiichemann and R. Holm
In addition multiple characteristic sharply delimited silicotic nodules with concentrically arranged dense collagen fibers and central necroses with occasional calcifications are seen (Fig. 2, 3)' These changes do not differ from those seen in hilar lymph nodes in pulmonary silicosis. There are thousands of polygonal doubly refractile foreign bodies particulary within the diffuse scar and granulation tissue. They are found in smaller numbers mostly in the periphery of the silicotic nodules many of them being completely free of demonstrable foreign material. Some of the silicotic nodules are completely calcified. After preparation of paraplast blocks for light microscopy, a piece of tissue was studied with the scanning electron microscope at 30 kV (Fig. 4, 5). The sample which had been fixed in sodium phosphate-buffered neutral formalin was air dried and coated with carbon. This preparation technic allows the combination of imaging and microanalysis by means of an energy dispersive X-ray spectrometer. The X-ray spectrum of the fixed tissue containing the crystals reveals the silicon content in addition to other com-
Fig. 4. Scanning electron micrograph of scar tissue with polygonal quartz crystals (largest crystal in center of picture). X 200.
Unusual Silica Granulomas of the Skin .
203
ponents derived from the tissue and the buffer (Fig. 6 a). When the electron beam was focused on one of the crystals, e.g. the one depicted in Figure 5, the spectrum shown in Figure 6 b was obtained which only exhibits the element silicon and is identical with the spectrum of the residual particles after incineration (Fig. 6 c) and of isolated crystals from scouring powders such as ATA (Fig. 6 d). The energy dispersive X-ray spectra do not indicate the light elements with atomic numbers < 9, in this case the oxygen. To be sure that the particles were SiO~ in the form of crystalline quartz and not glass, the remainder of the tissue was incinerated. 0.6 g white powder were recovered from this residue of onl y one biopsy. The Debeye-Scherrer pattern of an X-ray diffraction of this powder definitely revealed coarse crystalline quartz. In summary, the crystalline doubly refractile material which is responsible for the foreign body reaction and the production of silicotic nodules in the axillary lymph nodes consists of pure SiO~ (quartz).
Fig. 5. Scanning electron micrograph of isolated quartz crystal at higher magnification. X 5,900.
204 .
K. Kiichemann and R. Holm p
Q.
b.
c.
d.
1,7 2,3 3,4
IT
Fig. 6. Ener gy dispersive X- ray spectr a obta ined und er the scanning electron microscope. Abscissa: energy of x-rays , (a) Tissue fixed in buffered neutral formalin and containing quartz crystals (buffer contains sodium phosphate) . Note silicon peak. (b) Isolated quartz cry stal (see Fig. 5). (c) Residue after incinerat ion. (d) Isolated crystal from ATA (Ge rman scourin g powder) for comparison.
Discussion The case presented her e exhibits the characteristic features of silica granulomas. It must be assumed that the surgery done 26 years previously at the site of th e present lesion has someho w to do with the accidental implantation of silica. The long hospitalization (3 months) ma y indicate a severe injury treated at th at time, but unfortunately a precise history of adequate exposure to a specific agent is not available. The sudden rapid and recurrent appearance of granulomas after 26 years is a typical feature of these lesions as is indicated above. However, the large amount of silica present and the site and extent of the lesion w ith final compromise of the large ax illary blood vessels seem to be very unusual. In addition, the involvement of lymph nodes with multiple silicot ic nodules has not been described previously in skin lesions. It is not the purpose of this report to clarify the long delay of granuloma de velopment . Several th eories have been advanced. V isible silica particles are in the ra nge of I to 1 0 0 11m (Fig. 4, 5). Such large particles
Unusual Silica Granulomas of the Skin .
205
apparently do not evoke a granulomatous reaction. According to Shelley and Hurley (1960) silica must be in a colloidal state in order to be able to elicit a typical granulomatous reaction. This "critical release of colloidal silica" which is due to "slow chemical weathering" may take many years and is thought to be the reason for the long delay between silica implantation and granuloma development in the skin. According to the above authors "the rate of reaction of the body to quartz is inversely proportional to the size of the particle". Other authors (Epstein, 1967; Rank et al., 1972) favor a granulomatous hypersensitivity reaction. According to Rank et al. (1972) "the pathological process occurring in silicon granuloma of the skin appears to be rather different from that in lung silicosis". In pulmonary silicosis, small silica particles are engulfed by macrophages and enclosed within intracellular phagosomes. The phagosomal membrane is disrupted by lysosomes leading to cell death. Dead macrophages induce the typical fibrogenic response. According to Rank et al. (1972) cutaneous silicosis is characterized by "an epithelioid response which is most characteristic of hypersensitivity ". The lymph nodes of our case do contain typical silicotic nodules as seen in pulmonary silicosis as well as diffuse epithelioid cell granulomas (Fig. 2, 3). Perhaps several mechanisms are operative in the development of silicainduced extrapulmonary lesions. The main primary difference between pulmonary and extrapulmonary silicosis is a matter of particle size. Particles in lung silicosis are in the range of I to 5 urn (average 2 urn). Large particles such as seen in skin lesions are usually removed from the lung before they reach the terminal air passages. However, just as in pulmonary silicosis, in the skin only the small particles seem to be significant in the development of silica granulomas. Whatever the mechanism, the large size of the original particles in our case precluded their entry into the lymphatic channels. After a long interval they must have finally been broken down to smaller particles which initially excited a local foreign body reaction in the skin. They were then probably picked up by macrophages and carried to regional lymph nodes where they elicited an epithelioid response that differs from the foreign body granulomas seen in the primary lesion of the skin. Such phagocytosis of particulate matter is known to be an important first step in the initiation of primary immune responses. The silicotic nodules, however, are in no way different from those found in mediastinal lymph nodes. This finding does not support the assumption of Rank et al. (1972) that the process leading to lung silicosis is in all respects rather different from that in skin silicosis.
206 . K. Kiichemann and R. Holm
Acknowledgments: We are grateful to Drs. L. van Beeck, Chief, Department of Surgery, and D. Kamp, St.-Josef-Krankenhaus Leverkusen, for permission to report the case of this patient under their care and for obtaining follow-up information for this study. We wish to express our appreciation to Dr. E. Scherz, Medical Service, Bayer AG, for his cooperation in this investigation. Dr. Born, Bayer AG, kindly provided the Debeye-Scherrer pattern of the mineral ash. We are indebted to Prof. H. Gartmann, Department of Dermatology, and Prof. R. Fischer, Chairman of the Department of Pathology, University of Cologne, for advice and discussions. We are also grateful to Prof. G. Pfefferkorn, Director of the Institute for Medical Physics, University of Miinstcr, for valuable suggestions.
References Degos, R., and Civatte, J.: Das Silikosegranulom der Haut. Hautarzt 10, 106-110 (1959) Epstein, W. L.: Granulomatous hypersensitivity. Progr. Allergy II, 38-88 (1967) Johnson, F. B.: Crystals in pathologic specimens. Path. Annu, 7, 321-344 (1972) Knight, C. R.: Silicon granuloma of skin: Case report. Brit. J. Plast. Surg. 15, 2I 3-2 15 (1962) Rank, B. K., Hicks, J. D., and Levie, M.: Pseudotuberculoma granulosum silicoticum. Brit. J. Plast, Surg. 25, 42-48 (1972) Shelley, W. B., and Hurley, J. H.: The pathogenesis of silica granulomas in man: a non-allergic colloidal phenomenon. J. invest. Derm. 34, 107-123 (1960)
Received August 10, 1978 . Accepted October 2, 1978
Key words: Silica granuloma - Foreign body granuloma - Epithelioid cell granuloma - Granuloma - Lymph nodes
Dr. Klaus Kiichemann, Pathologisches Institut des Stadtischen Krankenhauses, Dhiinnberg 60, D-5090 Leverkuscn I