Case Number : Case 16 Posted By: Guest

Phillip McKee - Overseas consultations (USA) Wrote:

Many thanks Donald for your compliment it is very much appreciated.

Submitted on 01/07/2010 21:15
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Phillip McKee - Overseas consultations (USA) Wrote:

The features are those of mild hyperkeratosis, subtle interface change, a dense lymphocytic infiltrate and telangiectasia. The superficial dermis appears hyalinized. The specimen comes from a patient with discoid lupus eruthematosus. Systemic lupus erythematosus enters the differential diagnosis since the interface changes are subtle. One point lymphocytic vasculitis should show blood vessel wall damage with fibrin deposition etc which is not present in this image. Pityriasis lichenoides should show parakeratosis, lymphocyte exocytosis and at least a few necrotic keratinocytes. The lymphocytic infiltrate is heavier than one would generally expect to see. Lyme disease does not show interface change. As mentioned plasma cells are often present. Many thanks to all who contributed.

Submitted on 01/07/2010 21:14
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Donald Carman - (USA) Wrote:

Thanks Dr McKee for providing this educational site - the images are far superior to any other site I have seen including dermpedia. This is a difficult case but I considered lupus. No red cell extravasation, parakeratosis or tight lymphocytic cuffing as seen in pityriasis lichenoides chronica. Would love to hear your opinion.

Submitted on 01/07/2010 20:44
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Mona Abdel-Halim - Dermatology Department, Faculty of Medicine, Cairo University (Egypt) Wrote:

With the clue of interface change, which I think is so subtle (I missed it on the first look), and together with the lymphocytic vasculitis I will go for pityriasis lichenoides.

Submitted on 01/07/2010 18:06
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Khalid Khan - (UK) Wrote:

Interface change with lymphocytic infiltrate can only be lupus or pit. lichenoides. If plasma cells I would include secondary syphillis. Thank you for the clue Dr McKee as I did not see the subtle interface change on first look.

Submitted on 01/07/2010 17:54
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Wayne Grayson - (Johannesburg, South Africa) Wrote:

I found this very tricky to interpret without a clinical history or an image at higher magnification. There seem to be some large atypical cells and occasional melanophages interspersed among the lymphocytes. I'm concerned about a regressing melanoma, but could be horribly wrong!

Submitted on 01/07/2010 16:39
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amira tawdy - cairo university (Egypt) Wrote:

sorry l meant lymphomatoid granulomatosis and not lymphocytic

Submitted on 01/07/2010 16:15
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Phillip McKee - Overseas consultations (USA) Wrote:

This case is certainly provoking a wide range of differential diagnoses (as it should). Focus on the interface change!!

Submitted on 01/07/2010 15:15
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Eman El-Nabarawy - (Egypt) Wrote:

Patchy dense Lymphocytic infiltrate. DDx of the 7 L's especialy: LE ( as a small focus of interface dermatitis is seen).

Submitted on 01/07/2010 14:56
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Brian Newbold - (UK) Wrote:

Diagnosis is Erythema chronicum migrans

Submitted on 01/07/2010 13:00
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Brian Newbold - (UK) Wrote:

Diagnosis is Erythema chronicum migrans

Submitted on 01/07/2010 13:00
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Jonathan Shelton - (UK) Wrote:

Interface change with lymphocytic infiltrate - dd. lupus, pityriasis lichenoides.

Submitted on 01/07/2010 08:37
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Miah Singh - (UK) Wrote:

I need to see fibrinoid necrosis to accept a diagnosis of lympocytic vasculitis. I dont think the infiltrate is atypical - could this be a diagnosis of Jessner's lymphocytic infiltrate

Submitted on 01/07/2010 07:49
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Carlos L. - (Spain) Wrote:

Dermal lymphoid infiltrate with small lymphocytes admixed with atypical ones; could this be Sezary's syndrome?

Submitted on 01/07/2010 07:45
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Amira tawdy - Cairo university (Egypt) Wrote:

I SUGGEST THE FOLLOWING d.d| Lymphocytic granulomatosis Lymphocytic vasculitis and actinic reticuloid

Submitted on 01/07/2010 07:44
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Mona Abdel-Halim - Dermatology Department, Faculty of Medicine, Cairo University (Egypt) Wrote:

I can seen dense lymphocytic infiltrate around and within the wall of blood vessels in the upper dermis (tight cuffing around blood vessels). A picture of lymphocytic vasculitis. This pattern is seen in many disorders. Apart from very mild spongiosis and some thining of the epidermis, I can't find clues for a specific diagnosis. As I know, Lyme disease (Erythema chronicum migrans) contains abundant plasma cells. I don't find them abundant in this section. So my diagnosis will be: Lymphocytic Vasculitis for differential diagnosis.

Submitted on 01/07/2010 06:39
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Eduwiges Martínez - Hospital Gea González (in training) (Mexico, City) Wrote:

Lymphocytic vasculitis

Submitted on 01/07/2010 04:53
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Rodrigo Restrepo - UPB (Mdlln. Colombia) Wrote:

Sorry......Lyme disease

Submitted on 01/07/2010 03:03
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Rodrigo Restrepo - UPB (Mdlln. Colombia) Wrote:

Lime disease

Submitted on 01/07/2010 03:00
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