LAUSR

Dear Editor, Granuloma Annulare (GA) is a benign inflammatory skin disorder that commonly presents as annular grouped papules and plaques. Clinically, GA can assume a variety of forms including localized or generalized variants. The localized form is most common and displays a predilection to dorsa of the hands or feet. In contrast, the generalized variant is defined by the presence of 10 or more skin lesions or widespread annular plaques affecting the trunk or extremities. Contrary to the localized form, generalized GA (GGA) is less common, occurs later in life, and has a more chronic and unpredictable course. Associations are an area of special interest in the study of GA. We herein describe a case of GGA manifesting in the context of cryptogenic organizing pneumonia, a form of interstitial lung disease. We report on a 78-year-old woman, known to have clinically and radiologically proven cryptogenic organizing pneumonia treated with oral azathioprine as well as several short courses of oral steroids for her flares. She presented with a 1 year history of a persistent asymptomatic rash present diffusely over the back, chest, abdomen, and the upper and lower extremities. The rash consisted of minute, erythematous, and slightly infiltrated papules, macules and patches displaying confluence in several areas, especially over the trunk (Figure 1A,B). Annular arrangement was absent. Punch biopsy revealed a dermal interstitial, predominantly histiocytic inflammatory cell infiltrate with scattered multinucleated giant cells associated with increased dermal mucin deposition (Figure 1C,D). Based on clinicopathologic findings, GGA was diagnosed in a setting of cryptogenic organizing pneumonia (Figure 2). Basic work-up for possible underlying disorder including diabetes, dyslipidemia, and thyroid disease was done and was normal. Doxycycline 100 mg twice daily was administered with significant improvement with almost complete resolution of the skin lesions after 2 months of treatment. As the etiology of GA remains cryptic, description and elucidation of the associated conditions might yield a deeper understanding of the underlying GA pathogenesis. GGA has been linked to a variety of autoimmune, neoplastic, and infectious disorders, of which diabetes mellitus, lipid metabolic disorders, and thyroid diseases are most commonly associated. In addition, multiple lung-based pathologies have contributed to the growing list of GGA associations. GA has been