Granulomatous Inflammation with Chronic Folliculitis as a Complication
of Bee Sting Acupuncture
Indian J Dermatol Venereol Leprol, 2013 Jul-Aug;79(4):554
Sir,
Bee sting therapy is one of the traditional herbal medical
procedures that has been widely used for the treatment of chronic recalcitrant
neuralgia and arthralgia in Asian and Middle Eastern countries, and is also
called apitherapy. There are two methods of this therapy, one is stinging
directly to the treatment site [Figure 1] and the other is injecting the
artificially extracted venom from a bee. The substrates that compose the venom
of a bee have anti-inflammatory and analgesic effect. The bee leaves poison sac
and neural plexus when stinging, and the retained sting materials at the
treatment site may induce inflammation and granulomatous reaction.
A 50-year-old man visited our clinic complaining of
erythematous papules and nodules with tingling sensation on his back [Figure 2]
which showed wax and wane for the past 3 months, despite he had been treated
with intralesional injection of steroid in a private clinic. He had no specific
history but received bee sting acupuncture for several years in an oriental
medical clinic due to his back pain. The skin lesions occurred after 2-3 years
from the apitherapy procedures, directly at the sites that received the
acupuncture. Histopathologic findings of biopsy specimen taken from the back
showed perifollicular dense inflammatory infiltration composed of lymphocytes,
plasma cells, and histiocytes [Figure 3]a and b. Around the perifollicular
infiltration, ruptured granulomatous reaction composed of epitheloid cells and
lymphocytes was shown [Figure 3]c. There was no giant cell or foreign body in
the whole specimen. Special stains, Gomori methenamine silver (GMS) and
diastase-periodic acid-Schiff (d-PAS) revealed negative findings. The patient
was diagnosed as chronic folliculitis and granuloma caused by bee sting
acupuncture treatment. For anti-inflammatory effect, he was treated with oral
and topical antibiotics for a short period. The lesions showed slight
improvement but the patient was not able to be followed-up…
Folliculitis is an inflammation in the perifollicular area
that presents as erythematous papules and pustules on the trunk, neck and groin
area. The causes of folliculitis are mostly infection, bacterial organisms,
fungi such as Pityrosporum, viruses, and demodex. Histopathologic findings of
chronic folliculitis differs from acute folliculitis, that it shows perifollicular
infiltration composed of lymphoid cells, histiocytes and plasma cells rather
than neutrophils.
Granulomatous inflammation is a distinctive inflammatory
pattern characterized by granulomas, containing epitheloid histiocytes. Of the
five histological types of granuloma, foreign body granulomatous reaction is
divided into two subtypes, allergic and non-allergic. Foreign body type giant
cells and foreign body surrounded by numerous histiocytes and lymphocytes are
characteristically visualized in the non-allergic type. Besides, granuloma
composed of histiocytes is seen in the allergic type, and phagocytosis of
foreign body is not seen. [2] The granuloma of this patient is suggested to be
an allergic type foreign body granulomatous reaction due to remained poison sac
or neural plexus in the skin, not due to the stinger which should have been
discovered in the serial section of the specimen.
Although several reports had been published in Korean
literatures, there are only five reports of complications of bee sting
acupuncture in English literatures, since apitherapy is usually performed in
Asian and Middle Eastern countries. Only one case of the five English
literatures is a dermatologic complication. Therefore, we report the first case
of chronic folliculitis associated with granuloma as a complication of bee
sting acupuncture therapy, and no reports of chronic folliculitis combined with
granulomatous reaction as in our case have been reported.
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