British Journal of Dermatology (1977) 96, 673.

Sarcoid granulomas of the skin produced

by acrylic and nylon fibres
J.CORTEZ PIMENTEL
Department of Pathology of Hospital Pulido Valente and Institute of Pathology, Faculty of
Medicine, University of Lisbon, Portugal

Accepted for publication 6 December 1976

SUMMARY
The introduction into the skin of organic or inorganic substances can produce sarcoid-like granulomas.
Two new granulomas of this type are described related to acrylic and nylon fibres. The aetiological
diagnosis of such lesions can be confirmed by the identification of these synthetic materials within the-
granuloma cells, using histochemical techniques used in the textile industry. An 'individual factor',
probably immunological in nature, may be implicated.

Synthetic fibres are polymers obtained by chemical synthesis, and are largely used as textile materials.
Nylon, whose polymer is a polyamide, and acrylic fibres, whose monomer is acrylonitrile, are synthetic
fibres. In this study two new sarcoid type granulomas, due respectively to acrylic and nylonfibres,are
described. One of the patients had been subjected to prolonged occupational exposure to nylon dust;
granulomatous lesions due to inhalation of this material, similar to those described in the respiratory
disease due to synthetic fibres (Pimentel, Avila & Louren^o, 1975), were found in her lung.

CASE REPORTS
Case I. A 32-year-old, female nurse, complained of a painless, small, hard nodule in her left sole.
A month previously the nodule had increased to the size of an acorn and the foot became swollen. An
X-ray of her foot showed no changes. Histology of the nodule showed that the dermis and subcuta-
neous tissue were infiltrated by a sarcoid type granuloma, containing a number of foreign body,
Langhans type giant cells (Fig. i). These contained vacuoles and slits with inclusions of a birefringent,
fibrillar material. At the periphery of some of the granulomas long, birefringent, fibrillar filaments
with dark brown or yellowish brown pigmented areas were also observed (Figs 2 and 3). Ziehl-
Neelsen, Gomori & Unna-Pappenheim stains did not reveal acid-fast rods, fungi or leishmania. It was
not possible to culture tubercle bacih from the tissue removed. A chest X-ray and routine laboratory
tests were normal. The Kveim test was negative. The patient reported that she frequently walked bare
foot on acrylic carpets at home.
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Case 2. A 48-year-old female, who worked in a nylon fibre bag factory, noted a painless, firm nodule
the size of an acorn on the inner surface of her right index finger, 5 months before clinical examina-
tion. The nodule increased in size and began to interfere with her work. The patient said that, during
her work, she had frequently wotinded the finger where later the nodule developed; until a short time
before the wounds had healed promptly. An X-ray of her hand showed no bone or joint changes.
Histology showed a sarcoid type granuloma with some foreign body, Langhans type giant cells. These
cells contained vacuoles and slits (Fig. 4) with inclusions of birefringent fibrillar material. Acid-fast
rods, fungi and leishmania could not be demonstrated with appropriate staining techniques. Culture
of part of the surgical specimen was negative for tubercle bacilli. A lobectomy had been performed 5
years before for bronchiectasis. The pulmonary histopathology showed dilated bronchi partially
stirrounded by fibrosis, with histiocytes and fibroblasts producing granulomatous nodules. Within
the histiocytes many birefringent, fibrillar inclusions were seen.

METHODS
Techniques usually employed in textile chemistry for the identification of acrylic and nylon fibres
(Koch, 1963; Algerino, 1969; the Textile Institute, 1970), adapted for histophysical and histochemicai
examination (Pimentel, Avila & Louren9o, 1975), were applied. This study was carried out on fresh
and paraffin embedded samples of acrylic fibres from the carpet (Case i) and of the nylon fibre dust
(Case 2). Histological examination of the skin (Case 2) and lung (Case 2) lesions was performed on
fresh and paraffin embedded material, previously fixed in neutral 10% formalin. Both standard and
polarization microscopes were used.

FIGURE 5. Case I. Acrylic fibre from the carpet. Fine streaks on the surface and numerous pig-
mented areas. Compare with the inclusion in Fig. 3 ( x 460).

RESULTS
The microscopic study of the samples from the carpet showed fibres with fine streaks on the surface
and numerous areas of a black-brown or yellowish-brown pigment (Fig. 5), discretely birefringent.
The histochemicai characteristics were those of acrylic fibres (Pimentel et aL, 1975); insolubihty (4-2 N

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676 J.Cortez Pimentel
glacial acetic acid, 4-2 N hydrochloric acid, o-i N formic acid, 70% sulphuric acid, 80% phenol solu-
tion, m-cresol, 90% phosphoric acid, sodium hypochlorite, o-chlorophenol and cuprammonium solu-
tion), solubility (dimethyl formamide and nitromethane) and staining reactions (yellow with Meldrum
stain and Orange with Sevron orange). The analysis of nylon dust showed birefringent finely pig-
mented fibres. Histochemical studies showed the characteristics of nylon (Pimentel et al.y 1975):
insolubility (dimethyl formamide, sodium hypochlorite, cuprammonium solution and nitromethane),
solubility (4-2 N glacial acetic acid, 42 N hydrochloric add, o-i formic acid, 70'' „ sulphuric acid, 80%
phenol solution, m-cresol) and staining reaction (yellow with zinc chloride-iodine solution). Micro-
scopic study of the fibrillar and granular inclusions within vacuoles of the giant cells in the skin
granulomas showed birefringence, solubility and staining characteristics similar to those of the acrylic
fibres (Case i) and nylon fibres and dust (Case 2). The material within the lung (Case 2) also bad the
histophysical and histochemical characteristics of nylon. In Case i, in which the lesions showed some
quite large filaments, it was also possible to note a morphological structure similar to that of the acrylic
fibres (Fig. 5).

DISCUSSION
Two cases of sarcoid skin granulomas are reported, one on the foot pad of a patient who frequently
walked bare footed on an acrylic carpet, and the other on the finger of a worker who handled nylon
fibres. The lesions were due to the inoculation of those materials into the skin, as confirmed by
structural and histochemical similarities of the substances in the lesions to the samples of acrylic and
nylon fibres. In one patient (Case 2), who had had 20 years exposure to nylon, similar lesions developed
in the lungs. These lesions were granulomatous but not of the sarcoid type as seen in the skin, and
were similar to those reported as 'respiratory disease due to synthetic fibres' (Pimentel et al, 1975).
The incidence of such granulomas seems to be quite low, in view of the relative frequency of
situations which lead to skin wounds with these material, especially in textile workers. However, this
is also true for others skin granulomas such as those due to silica (Sommerville & Milne, 1950), talcum
(Fienberg, 1937), beryllium (Dutra, 1949), sulphonamides (Dupperat, 1952), zirconium (Rubin et al,
1956), wheat-stubble (Pimentel, 1972), cactus pricks (Winer & Zeilenga, 1955) and sea-urchin
(Kinmont, 1965). This suggests that the development of these lesions requires an 'individual factor',
probably of an immimological nature. An attempt to explain the formation of granulomas in the skin,
and other areas of the body, has been based on changes in hypersensitivity mechanisms of type IV
(Curtis, 1951; Shelly & Hurley, 1958; Kinmont, 1965; Pimental, 1972; Pepys, 1973) and possibly
type III (Spector & Heeson, 1969).
The aetiological characterization of new sarcoid granulomas of the skin can be attempted if the
lesions are carefully studied and the suspected causative substance is looked for within the lesions
using, when possible, appropriate histophysical and histochemical techniques.

ACKNOWLEDGMENT

This study was supported by the Centro de Anatomia Patologica da Universidade de Lisboa do
Instituto de Alta Culture.

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