Case Number : Case 59 Posted By: Guest

Phillip McKee - Overseas consultations (Arizona, USA) Wrote:

The patient had monoclonal cryoglobulinemia. The deposits were D-PAS positive. The field comes from deep to an ulcer. Many thanks for all of your contributions.

Submitted on 31/08/2010 20:20
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Marcela Saeb Lima - MSLDermatopato (Mexico, City) Wrote:

Occlusive vasculopathy Would do PAS stain and Masson trichrome

Submitted on 31/08/2010 15:59
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Ana Cristina Ruiz S - Universidad CES (Medellín, Colombia ) Wrote:

Angiosarcoma

Submitted on 31/08/2010 15:46
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Lushen Pillay - Wits Dermatology, South Africa (South Africa) Wrote:

Vasculitis - ? DIC

Submitted on 31/08/2010 15:04
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Phillip McKee - Overseas consultations (Arizona, USA) Wrote:

Good morning. You are all doing very well and covering the differential diagnoses nicely.

Submitted on 31/08/2010 14:27
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Juan Carlos Garcés - Hospital Oncológico / Hospital Luis Vernaza (Guayaquil Ecuador) Wrote:

Fibrin thrombus.. could be Disseminated intravascular coagulation

Submitted on 31/08/2010 14:24
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Saleem Taibjee - Warwick () Wrote:

I agree with others' comments so far. Looks like a vascular process. The occluded vessel raises possibility of vasocclusive process including cryoglobulins. Occasional neutrophils in the endothelium also raises possibility of vasculitis including polyarteritis and microscopic polyangiitis given the apparently deeper involvement of the process. The dissecting nature around dermal collagen made me consider the palisading neutrophilic dermatitis spectrum. But the endothelial cells do look a bit striking, and a suggestion of dissecting pattern made me also consider angiosarcoma here.

Submitted on 31/08/2010 10:44
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Eman El-Nabarawy - Cairo University (Egypt) Wrote:

My DD is: angiosarcoma, cryoglobulinemia with reactive angioendotheliomatosis.Oh, Very tough case.Thanks Dr Mckee for this lovely challenge. Cann't wait to subscribe to the online course.Hope to start in time.

Submitted on 31/08/2010 00:53
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Mona Abdel-Halim - Dermatology Department, Faculty of Medicine, Cairo University (Egypt) Wrote:

First of all, this is a difficult case (A Brain Teaser!!). I can see lots of things: In the centre there is what looks like an occluded blood vessel with intraluminal esinophilic material and few neutrophils in the wall together with extravasated RBC's, may be ?? mixed cryoglobulinemia. In addition I can see 2 blood vessels with intravascular proliferation of the endothelial cells occluding the vascular lumina, I thought of reactive angioendotheliomatosis in association with cryoglobulinemia. I can also see what looks like epithelioid like endothelial cells diffusely infiltrating the dermis (Something that looks like ??? diffuse dermal angiomatosis that occurs with severe atherosclerosis). Could this section present both conditions??. Another possibility came to me from the presence of epitheliod like endothelial cells dissecting in between the collagen bundles together with dissecting extravasated RBC's that this could be angiosarcoma (poorly diff) with possible DIC due to Kassabach Meritt syndrome. DIC also can be associated with reactive angioendotheliomatosis. The final possibility (which I think is the most likely one) is that I am totally and horribly wrong!!! I tried to explain all what I am seeing!!! waiting to know the correct answer.

Submitted on 30/08/2010 23:42
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Wayne Grayson - (Johannesburg, South Africa) Wrote:

This is a very tough case in the absence of clinical history and a view at lower magnification. I think I am seeing prominent dermal vessels in the immediate vicinity of an eccrine sweat gland coil, with one of these vessels showing apparent luminal occlusion by eosinophilic material. I think this could be DIC or cryoglobulinaemia. On the other hand, I could be horribly wrong...

Submitted on 30/08/2010 17:00
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