Case Number : Case 732 - 5 Apr Posted By: Guest

Looks interesting as usual... Superficial and deep infiltrate, some wedge perception. The infiltrate as it appears in the last two images looks atypical. Lymphocytes with large hyperchromatic irregular nuclei. I think a mitosis is also seen. The epidermis in the second image appears necrotic and eroded with neutrophils beneath. The condition is chronic. Crops of pustules, localized to the buttock. I am thinking of regional (localized) pustular variant of LyP... Waiting to c other opinions!!!! Interesting case....

Wake up everyone!! Is Mona the only person brave enough to have a go at my
case?

LyP vs. other lymphoproliferatives such as marginal zone lymphoma. Immunoblast-like cells with central prominent eosinophilic nucleolus and hyperchromatic cleaved cells on Fig. 3. Suggesting CD 2,3,20,30, Bcl-2, Bcl-6 for differentials

Sorry Fig.5

Herpes incognito

? lymphomatoid papulosis, ? other lymphoproliferative disoder. Requires immunos.

LyP

Good morning, Dr. Richard Carr! You can put the blame for my delay on the different time zone.
Wedge-shaped pseudolymphomatous infiltrate in the dermis composed mainly of small lymphocytes with scattered large cells. Overlying an infiltrate of neutrophils, eosinophils and nuclear dust, there’s focal epidermal necrosis with cellular changes reminiscent of viral cytopathic effect. Herpes zoster???

Intetesting suggestion of herpes incognito by Rodrigo and herpes zoster by Robledo,,, but for 2 years??

LLC associated herpes virus infecction?

Sorry... Chronic Lymphocytic Leukemia (CLL) in skin with herpes virus infection associated?

Sorry for the delay. Had a busy day! An odd pseudolymphomatous insect bite reaction was what I thought based on the few Eosinophils and wedge shaped infiltrate. Herpes however sounds more liklely with the history and the suggestion of cytopathic cells in the epidermis.

Well done!!!!
The diagnosis is indeed Herpes (but simplex type II based on PCR and IHC).
We suspected Herpes on H&E but could not quite make a confident diagnosis
although I agree there is just a suggestion of a viral cytopathic effect in
the rather confluently necrotic individual keratinocytes in Fig 4. I also
wanted to you remember (as Mark and other pointed out) the pseudolymphomatous
and sometimes really quite worrying infiltrate associated with herpes infections
that can easily be mid-diagnosed as suggesting a lymphoproliferative disorder.
The suggestion of CLL is an interesting one but I cannot confirm it in this
particular case. Remember that ano-genital Herpes can be very chronic especially
in the setting of immunosuppression and the classic cytopathic inclusions
may be easily missed so it is a case of not forgetting to think about the
possibility. My thanks to you all for excellent responses today and to Dr
Heinz Kutzner for kindly confirming the diagnosis on molecular and IHC studies.
Enjoy your weekends.

Very nice case....