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Dr. Mona Abdel Halim's Blog

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Dr. Mona Abdel-Halim

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Diagnosis in medicine is all about gathering symptoms and information from history, signs from examination, findings from labs and investigations and putting them all in a proper context to reach a meaningful diagnosis.

In dermatopathology, it is very important to interpret histopathological findings in their proper context. Spongiosis in the epidermis does not necessarily mean that the diagnosis is eczema. Lymphocytes within the epidermis does not necessarily mean mycosis fungoides. Putting things in context is what makes us reach a proper diagnosis.

Interpreting features in the slide without knowing their exact context can result in fatal mistakes. Having enough clinical information is vital to envision what context you are dealing with. Unfortunately, clinicians sending biopsies may be not helpful at all in this issue.

I have received a slide for a second opinion. The given pathological diagnosis was poikilodermatous MF. The slide showed poikilodermatous changes namely atrophic epidermis, vacuolar degeneration, few focal interface lymphocytes, patchy upper dermal infiltrate and telangiectatic vessels. The staining quality of the slide was not perfect making the interface lymphocytes appear slightly hyperchromatic but they were not convoluted. Neither my colleague (Dr Eman El-Nabarawy) nor I were comfortable with the diagnosis of MF. We could not report on the given slide but we called the clinician and asked to examine the patient. On examination, the whole context was completely different. The patient had pruritic scaly erythematous and poikilodermatous rash on the nape, sides of the neck, front of the chest, breast, abdomen, thighs together with facial scaly erythema, heliotrope erythema of the eyelids, keratotic plaques on the elbows and a history of breast cancer treated by mastectomy, chemotherapy and hormonal therapy. We took two biopsies from the poikilodermatous lesions of the breast and abdomen. They showed hyperkeratosis, effaced epidermis, vacuolar degeneration, necrotic keratinocytes, thickened basement membrane and markedly telangiectatic blood vessels. One biopsy showed in addition superficial dermal sclerosis. The whole context was pointing to dermatomyositis (amyopathic). The patient now is being properly investigated and evaluated. Has the whole context been revealed to the first dermatopathologist, do you think the diagnosis would still have been poikilodermatous MF? I doubt.

My message is always ask for all the clinical data, it's your right to know everything in order to diagnose properly. The other thing is never comment on a bad biopsy. Badly prepared biopsies can be deceiving. The last advice is to dermatopathologists who are not clinicians, try to improve your clinical sense of dermatological diseases by seeing clinical cases, attending dermatology conferences, seeing photos of skin eruptions. A good clinical sense is life saving for you and for your patient.
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