Case Number : Case 820 - 8th August Posted By: Guest

Bullous pemphigoid

I see an epidermis with mild spongiosis accompanied by eosinophil exocitosis. There are some eosinophils also in the dermis together with neutrophils (fig. 3). I think this could be a initial Bullous pemphigoid or a drug reaction too, even without interface reaction. History of drug intake is important.

At first glance, it simulates a normal skin, but this apparent normality is debunked by a subtle interstitial infiltrate of scattered eosinophils, neutrophils and mast cells in a slightly edematous dermis. Bearing in mind the information that this biopsy was taken from abdomen, the presence of some stellate fibroblasts and gray-blue elastic fibers makes me think of physical urticaria induced by sun exposure.

I think this is cutaneous mastocytosis.....

Nothing exciting.Drug eruption.

I can see only one intraepidermal eosinophil. Maybe most of the cells that look like fibroblasts are, in reality, mast cells. So I agree with Dr. Sasi: cutaneous mastocytosis.

Agree with Maria and Igor...acute/early drug eruption.

Clinical of sudden onset confluent erythema and vesicles, without bullae, would support this slightly over BP.

Looking at the biopsy, I see a mixed sparse eosinophilic and neutrophilic interstitial infiltrate with subtle edema, telangiectasia, spongiosis, rare necrotic basal keratinocytes, and minimal eosinophil exocytosis. No parakeratosis is seen.

The differential would include an early (spongiotic phase) biopsy of bullous pemphigoid, but the urticarial pattern inflammation seems too sparse, too neutrophil predominant, and lacking in subtle subepidermal clefting to be an early BP, in my opinion.

Drug vs. urticarial stage of BP

Dear All the diagnosis was urticarial bullous pemphigoid. Direct IMF confirmed the diagnosis. Differential would have included a drug eruption on morphological grounds.