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Building Blocks of Dermatopathology

BAD DermpathPRO Learning Hub: Diagnostic Clues

Diagnostic Challenge
Interesting Case

Case Number : CT0004 Dr. Hafeez Diwan

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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59-year-old male with recurrent papular lesion on dorsal forearm for 2-3 months. He traveled to Grand Cayman 6 months ago an to Honduras within the last 2 years. The biopsy is from an ulcerated lesion on dorsal left forearm.

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Guest Engin Sezer - Histoplasmosis vs. botyromycosis
Arti Bakshi - Blue staining granules (?bacteria) with surrounding Splendore- Hoeppli phenomenon
?Botyromycosis ??Actinomycosis
Robledo F. Rocha - I go with botryomycosis unless special stains prove otherwise. Grains appear as basophilic granules rather than filamentous.
Dr. Richard Carr - Botryomycosis was my first consideration, most likely some Staphylococcus?
Dr. Mona Abdel-Halim - Botryomycosis is my first impression also,,, lovely :-)
Guest Jim Davie MD - Favor Staphylococcal botyromycosis (agree with Richard). The bacteria are forming closely packed, but distinct tetrads (squares of 4 cocci) plus clusters, which is common in Staphylococcus (doubt Micrococcus). I don't see filamentous bacteria suggestive of a coexistent Actinomycete. Differential Dx would include incidental cocciform impetiginization, as a distraction in a lesion caused by something else not easily seen in these photos (foreign body, fungus, etc). Staining for fungus would be prudent.
Dr. Hafeez Diwan - I called this botryomycosis.

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