In this section we have spot diagnoses posted on a daily basis since June 2010, now over 1700! You can review the archived cases and read the suggested diagnoses by users and the final comment by Dr Uma Sundram, the Editor-in-Chief and main spot diagnosis host. Case are uploaded each week day by 10 a.m. UK time with the correct diagnosis will generally be posted at 8 p.m. UK time. Why not view the most recent spot diagnosis and proffer a diagnosis?

Case Number : Case 911 - 16th December Posted By: Guest

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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The patient is a 39 year old man with four superficial erosions on the penis, present for 3 weeks. A biopsy is taken from the penis.

Case posted by Dr. Mark Hurt


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Guest Tiberiu Tebeica

Posted

There is a dense lichenoid infiltrate of mononuclear cells (lymphocytes, histiocytes and possibly plasma cells, although I don't see them well in these photomicrographs) with deep extension, associated with epidermal hyperplasia. There is also prominent endothelial swelling. In the clinical setting provided, this is likely a chancre of primary syphilis. Correlation with serology and/or staining for T. pallidum would be helpful.

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Guest Maria George

Posted

Mycosis fungoides. namely pagetoid reticuloisis is important differtial here.

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Sasi Attili

Posted

I agree on clinical grounds syphilis is a differential. However, I do not see many plasma cells. What about LP?

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Guest Maria George

Posted

LP classically has hyperkeratosis and not parakeratosis like this case.However, it can be drug-induced LP where you can see parakeratosis.But missing eosinophils though.
For me 2 horsesin the race till now $ and lymphoma or Scabies.

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Guest Romualdo

Posted

The extensive parakeratosis speaks against lichen planus and the absence of plasma cells against syphilis. I think lymphomatoid drug eruption a good idea!

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Sasi Attili

Posted

Parakeratosis is not an exclusion criterion for erosive LP, though I agree that it is usually focal and not confluent like in this case. Drug reaction is a good idea, though this is not quite 'lymphomatoid' in my opinion. Forgot to mention - PAS essential to rule out primary/ secondary candidal infection in view of the extensive parakeratosis.

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Guest Rodrigo Restrepo

Posted

[color=#1C2837][font=arial, verdana, tahoma, sans-serif][size=4]Drug-induced LP [/size][/font][/color]

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Robledo F. Rocha

Posted

I favor lymphomatoid drug eruption due to prominent lymphocytic epidermotropism with minimal spongiosis, and to non-necrotic vascular reaction displaying transmural angiocentric infiltrate of lymphocytes.

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Dr. Richard Carr

Posted

I suspect the plasma cells just have not had sufficient time to turn up! I am looking forward to seeing the T. pallidum stain.

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Mark A. Hurt MD

Posted

Here is the key immuno-stain. Answer at or around 14:00 CDT.

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE911_Image%2006.jpg[/img]

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE911_Image%2007.jpg[/img]

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Robledo F. Rocha

Posted

[color=#1C2837][font=arial, verdana, tahoma, sans-serif][size=4]Yes, this is chancre of primary syphilis.[/size][/font][/color]

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Mark A. Hurt MD

Posted

Yes, this is the chancre of primary syphilis.

In all these years of my practice practice, this is the first case of primary syphilis I have seen in the form of a case actually sent to me (as opposed to a study set or a lecture). I was also impressed by the paucity of plasma cells in the field. Syphilis was not my first diagnosis. My differential was lichenoid dermatitis vs lymphoma. I also had a Steiner done on this biopsy, and many spirochetes were identified, too, with that method -- but they were much more difficult to photograph; thus, I didn't post them here.

Parenthetically, I recall a case of secondary syphilis I diagnosed a few years ago -- only [i][u]after [/u][/i]the RPR was positive. I didn't consider it on the biopsy prior to the RPR -- so I simply missed it because I didn't consider it in the differential diagnosis. The lesson for me in that case was that it was also [u][i]minimally [/i][/u]plasmacytic. I swore I would never forget syphilis in unusual infiltrates after that error.

Clinically, the differential was chancroid from the dermatologist who sent in the biopsy.

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