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Dermatopathology
Tuesday, February 14, 2006 - 7:30 PM
International North Room
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Moderator:
Bruce R. Smoller
University of Arkansas for Medical Sciences
Little Rock, AR
Disclosure: The speakers have indicated they have nothing to disclose.
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Clinical histories are printed below.
Click on the case numbers for text and references of each case.
Click on each slide thumbnail image for an enlarged view
Submitted by:
Bruce R. Smoller
University of Arkansas for Medical Sciences
Little Rock, AR
67 year old woman with many erythematous papules, extensive joint pain, malaise and slight fever for months
Case 1 - Figure 1 -
Low power demonstrates papillary dermal edema and a brisk, diffuse infiltrate.
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Case 1 - Figure 2 -
Higher magnification demonstrates a neutrophilic infiltrate with possible vascular involvement.
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Case 1 - Figure 3 -
Abundant histiocytes are present, admixed with the neutrophils throughout the dermis.
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Case 1 - Figure 4 -
Another view demonstrates degenerative changes in the dermal collagen.
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Submitted by:
Bruce R. Smoller
University of Arkansas for Medical Sciences
Little Rock, AR
45 year old with 4 year history of hemodialysis secondary to end-stage renal disease secondary to diabetes mellitus. Now with thickened, somewhat rigid extremities (more on lower), rule out scleroderma
Case 2 - Figure 1 -
Fibrous septa between subcutaneous fat lobules are greatly expanded.
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Case 2 - Figure 2 -
Higher magnification demonstrates an accumulation of spindle shaped cells.
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Case 2 - Figure 3 -
The spindle shaped cells course in a stroma that has increased mucin as well as fibrotic changes.
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Submitted by:
Jennifer M. McNiff
Yale University School of Medicine
New Haven, CT
40 year old female who presented with erythroderma after years of atopic dermatitis. Important underlying history (initially withheld) is that she is HIV+ and has very low CD4 counts
Case 3 - Figure 1 -
At low power, there is a band-like lymphocytic infiltrate with psoriasiform epidermal hyperplasia and dermal fibrosis.
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Case 3 - Figure 2 -
There is minimal epidermal spongiosis, with dry parakeratosis. The papillary dermal collagen shows wiry fibrosis, and the infiltrate is relatively dense.
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Case 3 - Figure 3 -
Note the presence of intraepidermal lymphocytes in the absence of spongiosis, forming small Pautrier microabscesses. Some of the lymphocytes are enlarged with irregular nuclear contours.
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Case 3 - Figure 4 -
Scattered intraepidermal collections of lymphocytes are identified in association with irregular psoriasiform epidermal hyperplasia and hyperkeratosis without spongiosis.
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Submitted by:
Jennifer M. McNiff
Yale University School of Medicine
New Haven, CT
53 year old man with nodule on the back. Additional nodules on the face at roughly the same time. Underlying history of CLL
Case 4 - Figure 1 -
Low power image showing diffuse infiltration of the dermis by histiocytes and multinucleate giant cells. A few neutrophils and lymphocytes are present. The epidermis is predominately spared.
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Case 4 - Figure 2 -
Geographic areas of altered collagen are present within the inflammatory infiltrate in the dermis.
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Case 4 - Figure 3 -
Palisades of histiocytes surround degenerated collagen. Multinucleate giant cells are numerous, some show bizarre shapes.
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Submitted by:
Kim M. Hiatt
University of Arkansas for Medical Sciences
Little Rock, AR
A 47 year old woman with multiple myeloma has a hospital course complicated by myocardial infarct, respiratory failure and acute renal failure. She has developed indurated violaceous patches on the posterior legs and back.
Case 5 - Figure 1 -
This view shows a relatively normal epidermis and dermis with basophilia of the deep dermis
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Case 5 - Figure 2 -
This view of the deep dermis shows abundant calcification of the dermal collagen. This likely represents dystrophic calcification of ischemic collagen
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Case 5 - Figure 3 -
On high power calcification is seen in small vessels of the deep dermis. This is the key to the diagnosis.
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Submitted by:
Kim M. Hiatt
University of Arkansas for Medical Sciences
Little Rock, AR
A 57 year old man has scarring and erosions on the dorsum of both hands. He has received occasional therapeutic phlebotomy for iron overload.
Case 6 - Figure 1 -
This low power image shows an acanthotic and hyperkeratotic epidermis on sun exposed skin with exuberant solar-elastosis. .
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Case 6 - Figure 2 -
On higher powerof the dermal-epidermal junction you should notice basal vaculopathy and mild spongiosis as well as changes in the vessels of the superficial dermis. These superficial vessels have a thickened, eosinophilic wall.
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Case 6 - Figure 3 -
On high power of the superficial dermis you note increased vascularity, a mild lymphocytic infiltrate and increased collagen deposition, changes characteristic of wound healing. Note also the vascular changes described with figure 2 and the abundant solar elastosis.
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Submitted by:
James W. Patterson
University of Virginia Health Sciences Center
Charlottesville, VA
14 year old boy with a history of chronic diarrhea, sinopulmonary infections, and asthma. He had high titers to islet cell and thyroid microsomal antigens. Cutaneous findings in the past had included eczematous dermatitis. He recently developed prurigo nodularis-like lesions on abdominal skin and on the extremities. A biopsy was taken of a nodular lesion from the right forearm
Case 7 - Figure 1 -
This view shows pseudoepitheliomatous hyperplasia and a mixed dermal infiltrate. Subtle subepidermal clefting can be seen. There is evidence for "vertical streaking" of papillary dermal collagen. Ulceration was apparent on low power magnification.
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Case 7 - Figure 2 -
On high power magnification, numerous eosinophils can be seen in the dermal infiltrate.
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Submitted by:
James W. Patterson
University of Virginia Health Sciences Center
Charlottesville, VA
A 46 year old woman had a two week history of tender, erythematous papules and nodules on the hands, arms, and legs. She did not have fever, chills, or systemic symptoms, and there was a negative history for arthritis. A medication history was obtained. The clinician's differential diagnosis included erythema elevatum diutinum, erythema nodosum, and "lymphocytic infiltration". Biopsy from lesion on the left arm of a 46 year old woman
Case 8 - Figure 1 -
At low power, there is a moderately dense dermal infiltrate with angiocentricity.
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Case 8 - Figure 2 -
The infiltrate has perivascular and interstitial components. Granulomatous inflammation can be identified.
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Case 8 - Figure 3 -
Lymphocytes and granulomatous elements predominate, but a few granulocytes can also be identified. Both neutrophils and eosinophils were seen on high power.
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Case 8 - Figure 4 -
Endothelial swelling and permeation of vessel walls by inflammatory cells indicate a degree of vasculitis. Some areas are suggestive of "granulomatous vasculitis".
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