Case Number : 84 Posted By: Guest

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

The final diagnosis is non-lipidized Xanthogranuloma. Well done for all the comments and discussion created. I will be posting tomorrow's case shortly but then I will be travelling abroad for 2 weeks and have ask Dr Iskander Chaudhry, Dermatopathologist from the UK to manage the spot diagnoses - he has seen the cases and has my diagnoses and comments. I hope to join you when I get back. Phillip

Submitted on 05/10/2010 22:50
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Mona Abdel-Halim - Dermatology Department, Faculty of Medicine, Cairo University (Egypt) Wrote:

Dear Dr McKee, if only one of us is right then I think he will be Dr Carr suggesting PEcoma. Although I said that I don't think it fits here because the cells in PEcoma must be claer or granular, I searched the internet looking for figures and papers of this rare entity. I feel that the clue is in the 2 slit like vascular spaces in the centre. The PEcoma cells are related to perivascular epithelioid cells and are said to proliferate around slit like vascular spaces. I read in a published article that the cells may vary from esinophilic to granular to clear. I think that immeadiately to the right of the vascular space on the right side there are some large cells (possibly epithelioid cells) that have clear to granular cytoplasm. I think another one is also seen a little bit to the right of them. As I said before, it crossed my mind early in the morning but my perception about it is a predominantly clear to granular cell neoplasm, but after I read in the published article and with the presence of the 2 slit like vascular spaces, some hyperchromasia and ? mitosis, I think it could be possible. So anxious to know the correct diagnosis, that was a real brain teaser!!!

Submitted on 05/10/2010 18:50
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Mona Abdel-Halim - Dermatology Department, Faculty of Medicine, Cairo University (Egypt) Wrote:

Dear Dr McKee, if only one of us is right then I think he will be Dr Carr suggesting PEcoma. Although I said that I don't think it fits here because the cells in PEcoma must be claer or granular, I searched the internet looking for figures and papers of this rare entity. I feel that the clue is in the 2 slit like vascular spaces in the centre. The PEcoma cells are related to perivascular epithelioid cells and are said to proliferate around slit like vascular spaces. I read in a published article that the cells may vary from esinophilic to granular to clear. I think that immeadiately to the right of the vascular space on the right side there are some large cells (possibly epithelioid cells) that have clear to granular cytoplasm. I think another one is also seen a little bit to the right of them. As I said before, it crossed my mind early in the morning but my perception about it is a predominantly clear to granular cell neoplasm, but after I read in the published article and with the presence of the 2 slit like vascular spaces, some hyperchromasia and ? mitosis, I think it could be possible. So anxious to know the correct diagnosis, that was a real brain teaser!!!

Submitted on 05/10/2010 18:50
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Eman El-Nabarawy - Cairo University (Egypt) Wrote:

Very difficult case. But I really like challenging cases.I have another DD since this morning but I am not sure, lymphoma, But I cant know the type? Any possible clues Sir, please. We are really exhuasted.

Submitted on 05/10/2010 18:41
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Phillip McKee - Overseas consultations (Arizona, USA) Wrote:

Well it is not an easy case to diagnose from a single image. I am glad you have all 'woken up' after Richard's comment!! One of you is right ... but which one ...

Submitted on 05/10/2010 17:57
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Juan Carlos Garcés - Hospital Oncológico / Hospital Luis Vernaza (Guayaquil Ecuador) Wrote:

Good morning everybody... I am lost..I have seen the picture for hours and I am not sure but the cells look like histiocytes to me. They have a lot of delicated cytoplams almost foamy, the núclei are oval. I cannot see atypia but I am concerned about the mitosis. I would considersom kind of histyocitosis like Eruptive histyocitoma or benign cephalic histiocytosis. But I cannot forget Atypical mybacteria.

Submitted on 05/10/2010 16:49
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Lushen Pillay - Wits Dermatology, South Africa (South Africa) Wrote:

Difficult to say. ? One of the Histiocytoses, but don't see any spindle cells, so thinking of Xanthoma Disseminatum/ BCH/ or Generalised Eruptive Histiocytosis ??

Submitted on 05/10/2010 16:14
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Eman El-Nabarawy - Cairo University (Egypt) Wrote:

Histiocytic infiltrate. DD: early juvenile xanthogranuloma, benign cephalic histiocytosis, eruptive histiocytoma.

Submitted on 05/10/2010 16:09
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Mona Abdel-Halim - Dermatology Department, Faculty of Medicine, Cairo University (Egypt) Wrote:

This section is puzzling me since early morning. Diffuse histiocytic infiltrate. Cells have pale to esinophilic cytoplasm. The majority of the nuclei are oval, few are reniform. No xanthomatization. There may be few lymphocytes also and may be ?? 1 neutrophil. Can't find much clues to which type of histiocytosis but I think the presence of few reniform nuclei with the oval nuclei may point to Benign Cephalic Histiocytosis. I am also thinking about the two vessels in the centre of the fild, they look different than the think one in the lower left part, I have been thinking about a clue related to the blood vessels but could not find an explanation related to histiocytic infiltrates. I know that generalized eruptive histiocytosis may show nesting around Blood vessels but the cells in this type of histiocytosis should be spindle shaped histiocytes as far as I know. The Idea of PEcoma crossed my mind in the morning as I looked to the 2 vessels in the centre. I think in PEcoma we have epithelioid or spindled cells that are clear to granular. Don't think that it fits here.

Submitted on 05/10/2010 16:07
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Miah Singh - Trainee (UK) Wrote:

Very difficult case - not sure ? granulomatous

Submitted on 05/10/2010 15:57
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Carlos B - Spain () Wrote:

Xanthogranuloma

Submitted on 05/10/2010 15:57
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Richard Carr - Warwick (UK) Wrote:

PECOMA as an after thought but I need some immunos!

Submitted on 05/10/2010 13:23
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Richard Carr - Warwick (UK) Wrote:

Is everyone sleeping today? I thought this looked like histiocytes and would be going to look up the histiocytic infiltrates like an early Solitary Eruptive Xanthogranuloma (SEX!!) or an indeterminate cell histiocytoma etc. I tried to think of any infection that would give you non-epithelioid macrophages (Leish, MAI, Leprosy) but was not overly successful! Tricky today.

Submitted on 05/10/2010 13:22
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ANDREW DANCKWERTS - JOHANNESBURG, RSA (WITS UNIVERSITY, JHB) Wrote:

LYMPHOPROLIFERATIVE DISORDER CHARACTERISED BY ANGIOCENTRIC AND ANGIODESTRUCTIVE INFILTRATION. FAVOUR: LYMPHAMOTOID GRANULOMATOSIS. DIFFERENTIAL DIAGNOSIS INCLUDES MYCOSIS FUNGOIDES AND EXTRANODAL NK/T-CELL LYMPHOMA OF ? NASAL TYPE.

Submitted on 05/10/2010 06:39
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