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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 820 - 8th August 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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65 year old male with new onset rash, vesicles, and confluent erythema. Two biopsies from the left anterior forearm and left abdomen were performed. The biopsy shown is from the left abdomen.

Case posted by Dr. Hafeez Diwan.


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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.

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Robledo F. Rocha

Posted

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.

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Sasi Attili

Posted

I think this is cutaneous mastocytosis.....

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Guest Maria George

Posted

Nothing exciting.Drug eruption.

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Guest Romualdo

Posted

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.

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Guest Jim Davie MD

Posted

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.

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Dr. Mona Abdel-Halim

Posted

Drug vs. urticarial stage of BP

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Iskander H. Chaudhry

Posted

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

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