Case Number : Case 562 - 3 Aug Posted By: Guest

Epidermal ulceration (adjacent epidermis shows acanthosis), neutrophils and apoptotic debris, syringometaplasia and in the 3[sup]rd[/sup] image there is necrosis of the sweat gland ducts (most likely due to ischemia) and haemorrhage. PAS, Gram and Groccott are required to exclude an infectious aetiology.
Syringometaplasia can be seen in areas of ischemia, adjacent to ulcers or healing surgical wounds. It may follow burn, radiation, cryotherapy or curettage. It also can occur in patients receiving chemotherapy for malignant tumours.

[b]The changes are most likely due to ischemia[/b].

DD: Dermatitis artefacta.

Decubitus ulcer.

This might just be a decubitus ulcer. However would like to rule out an infective etiology with PAS, Gram and ZN.

Overall the histologic changes appear to be those of ischemia. However, given the site (not typical for pressure ulcers) and history of progressive neuropathy and uveitis, I'm wondering if this patient might have CMV infection.

Histopathological manifestations are of Ischemia. Would think of vasculopathy caused by infective agent (ecthyma gangrenosusm due to pseudomonas infection for example or mengiococcemia etc...) or other causes such as: antiphospholipid syndrome, cryoglobulins, Ptn C and S deffeciency. In either cases, the associated neurological and occular manifestations are definitly related..

Thank you all for your contributions. I agree with Hazem's comments entirely.
This is a quite old case and I reported it as follows:
The biopsy shows an area of apparent wedge shaped dermal infarction
including necrosis of eccrine sweat coils and ecrine squamous
syringometaplasia in the adjacent dermis. There is a moderate
accompanying neutrophilic infiltrate in the vicinity of dermal
infarction, which extends on to the surface of the biopsy. No
specific organisms seen on gram stain.

Histologically my thoughts would include a local "pressure"
necrosis, possibly related to footwear in somebody with a
neurological problem. I cannot rule out a vascular problem in this
punch biopsy.