Ann. Medit. Burns Club - vol. VIII - n. 1 - March 1995

EXTENSIVE GRANULOMA PYOGENICUM COMPLICATING SEVERE BURNS

Departments of Surgery and Medicine, Armed Forces Military Hospital, Tabuk, Kingdom of Saudi Arabia

SUMMARY. A six-year-old girl, admitted over a seven-montb period with 70% tbird-degree bums to the Burns Unit of a tertiary Saudi Arabian medical centre, developed an unusual form of histologically confirmed, multiple, rubbery, widespread, vascular, giant-sized granuloma pyogenicum. Despite the corporeal severity of the flame bums accident and the benign cutaneous neoplasm, the patient made an uneventful recovery after multiple sessions of cryotherapy, meshed partial-thickness skin grafting, multiple intravenous antibiotics, albumin, blood and other fluids.

Granuloma pyogenicum is a benign vascular neoplasm of regenerating capillaries, primary to a traumatic ulcer of the skin and/or mucous membrane or secondary to a chronic cutaneous lesion where the skin surface has been damaged or infected, e.g. after pustular acne vulgaris. However, when such a condition fonns a foamy, red-balloon, "Michelin tyre" appearance with satellite lesions, it becomes a clinical diagnostic masquerade. This paper describes such a clinical problem.

A six-year-old Bedouin girl sustained kerosene bums to almost the entire body skin surface. After local first-aid measures applied at her home she was seen at the nearest medical facility, from where she was referred on 12 November 1992 to our hospital. Her family resides in the desert and the girl had no relevant family, dermatological, obstetrical or surgical history.
On examination, she weighed 16.05 kg and presented about 70% full-thickness burns in the left leg, right arm, axillae and antero-medial aspects of the chest. Other sites affected were: chest and abdomen (12%), upper limbs (13%), lower limbs (23%), buttocks (5%), back (12%), head (1%) and genitals (1%). All these areas were inoculated with tender, sessile, pedunculated, polypoid, papular, soft, rubbery, wet, red and vegetative swellings. The patient was hairy (for her age), pale, pyrexial and miserable-looking (Figs. 1, 2, 3).
The clinical picture was as follows: Hb = 9.7 gm%, Het = 80.5, platelets = 217 x 109/1, WBC = 15.7 x 109/1, HIV negative, hepatitis negative. Skin swab grew methicillin-resis-tant Stapkylococcus aureus sensitive to vancomycin, clindamyein and rifampicinum. Urine culture grew Providencia rettgeri and E. coli sensitive to ciprofloxacin. Blood group: 0 Rh positive, AST, ALT = NAD. Albumin = 18 g11, total protein = 46 g11. Creatinine = 33 pmol/1, urea 7.3 mniol/1. Alkaline phosphatase: 220 u/1 sodium, 133 mmol/1, potassium, 3.9 mmol/1. Blood culture: Staphylococcus organisms sensitive to vancomycin and ciprofloxacin. Urine culture: over 100,000 col/ml of E. coli and Pseudomonas aeruginosa sensitive to gentamycin and ciprofloxacin.

Fig. 1 - Shows polypoidal, multiple, ulcerative, coalescent granuloma pyogenicum at the bum site. Early stages of treatment. Fig. 2 - Post-treatment with cryotherapy, Fucidin cream, sytemic antibiotics and pressure application. Fig. 3 - Extensive granulorna pygenicum complicating severe burns.

Skin biopsy revealed a pedunculated skin tissue with characteristic crust and birefringent connective tissue fibres. There was a proliferation of the endothelial cells and numerous capillaries. At the base of the tissue the rete pegs were prominent while there was abundance of hair follicles with cyst-like horn structures. The histological diagnosis was ulcerated granuloma pyogenicum.

About five weeks after admission the patient was observed to have developed ball-like, rubbery, soft, polypoid nodules vegetating from the red raw painful burned areas. The patient was subjected to multiple sessions of blood transfusion, albumin infusion, variously bacteriologically dictated antibiotics, cryotherapy and serological monitoring of drug blood levels, e.g. of vancomycin. As the patient lived at some distance from the hospital, and because of the unavailability of her own skin for grafting, she had multiple sessions of grafting during her prolonged hospital stay. On 20 February 1993 she was subjected to partial thickness mesh-grafting and removal of some granulation tissue of the right arm, axilla and chest, and on 28 March, 25 April and 19 May 1993 to shaving of exuberant granulating tissue from the supra- and infra-umbilical and inguinal areas. The patient had a skin graft mesh 1-3 (taken from both legs and left forearm) applied to the gluteal and popliteal regions and the anterior and lateral chest wall.
Cryotherapy was performed using liquid nitrogen at 196 'C followed by Fucidin cream dressing with pressure bandaging. The patient made an uneventful recovery and was discharged on 7 August 1993. She continues to enjoy good health up to the time of writing.

Granuloma pyogenicurn (GP) is a cutaneous, vascular or red-coloured, papular, nodular condition that may occur either primarily or secondarily to a healing cutaneous swelling. It is a benign vascular tumour of the skin. Ro (1) described its pathogenesis, clinical features and mode of treatment. Subsequently Fromm and Asaad (2) amplified this further, maintaining that GP is a conglomeration of regenerating capillaries that has been associated with secondary infection even though no infective agent has been identified as a primary cause. Probably overgranulation of these tissues causes the exuberant growth of the tumour and this probably exposes its surface to recurrent or frequent traumatization.
Despite this macroscopic picture of GP, ultrastructural studies have shown that there is endothelial cell-proliferation with widening of the oedematous intercellular spaces and new vessel formation. Hence Marsch (3) felt that "capillary haemangioma" was a better term for GP. The tendency of GPs to bleed quite easily on slight trauma probably also supports this idea.
Cases of GP usually develop some four to five weeks after an initial primary skin lesion, as in our patient. But the satellite and the widespread distribution, as shown in the figures, are unusual and may create a diagnostic dilemma because the rubbery, vascular, nodular morphology simulates Kaposi's sarcoma, fibroma, epiloia of tuberous sclerosis, haemangioma, angiosarcoma, keloids, cutaneous leishmaniasis, keratoacanthoma and angiofibroma. However, the association of traumas in GP excludes these conditions (except keloids).
However, in rare cases, a melanotic malignant melanoma may mimic GP, although the latter is commoner in the head and trunk while the former is seen in all areas but seldom in the trunk (4).
The wide distribution of GP in the patient described here, coupled with the severity of the bums, aggravated the prognosis. Forjouh and Smith (5) have shown that the fatality rate in bums is affected by the extent and depth of the lesions and by the delay in initiation of treatment, but this patient was able to survive because therapy was initiated immediately (i.e. a few hours) after the accident. This therapy consisted of supportive intravenous fluids (5% albumin, blood, dextrose-saline), bacteriologicallydetermined antibiotics and intermittent surgical repairs with grafting of the affected skin.
Various modalities of treatment have been explored in the management of GP. Fong et al. (6), working in Singapore over an 18-month period, studied 41 GP patients with various lesions including capillary haemangiomas, cherry angiomas, telangiectasis and spider angiomas. Most of the patients responded very well to argon laser therapy, with few complications. Dejonckere et al. (7) reported exuberant GP as a post-surgical complication of endoscopy laser surgery for laryngeal papillornatosis. In contrast, Zaynoun et al. (8) treated most cases of GP surgically but reported a recurrence even after electrocoagulation. This surgical regime was also practised by Sen (9) in patients with palpebral, pedunculated conjunctival GP, although this method of treatment was complemented by diathermy.
Granuloma pyogenicum can be successfully treated only by repeated cryotherapy integrated with bacteriologically defined antibiotic cover, as in our patient. It is therefore suggested that cases of GP occurring in exposed parts should be treated exclusively with electrocoagulation with or without antibiotic therapy.

We would express our appreciation for the services and support of the nursing staff, the Dermatology and Burns Unit and the Communications Department, Armed Forces Military Hospital, Tabuk. The secretarial service of Ms Cecile M. Pefia is gratefully acknowledged.

RESUME. Une enfant âgée de six ans atteinte de brûlures de troisième degré dans 70% de la surface corporelle et hospitalisée pendant sept mois chez le Service de Brûlures d'un centre médical tertiaire en Arabie Saoudite a commencé à souffrir d'une forme inhabituelle de granulome pyogénique multiple, diffus, vasculaire, caoutchouteux, de taille géante et histologiquement confermé. Malgré les problèmes présentés par la sévérité corporelle des lésions causées par les flammes et par le néoplasme cutané bénin, la petite patiente est guérie sans incidents grâce à une série de sessions de cryothérapie, greffes cutanées mesh à épaisseur partielle, antibiotiques intraveineux multiples, albumine, sang et d'autres liquides.

BIBLIOGRAPHY

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