Case Number : Case 685 - 29 Jan Posted By: Guest

a broad differential diagnosis, thinking of parafinoma vs leishmaniasis vs rosai dorfman

Round holes of various sizes, considered of foreign body reaction, would perform a S100 to differentiate with lipocytes though.

As I failed in finding convincingly emperipolesis or infectious agents, I think cutaneous implant might explain all those round clear spaces and the multivacuolated and signet-ring cells.

Is this just a ruptured cyst with inflammation around it?

Dense infiltrate lymphohistiocytic with many plasma cells and few esinophils. Perifollicular accentuation. I think it is a form of deep folliculitis with rupture and foreign body reaction.

Factitial vs infectious process

[b]Favor Paraffinoma/Foreign Hydrocarbon injection[/b]

Dense lymphoplasmacytic and ?histiocytic superficial and deep dermal infiltrate with scattered eosinophils, and numerous signet cells, physaliferous cells, and larger, oil-droplet like spaces. The follicles/epidermis have what I believe are reactive changes to chronic inflammation.

My differential would include:
1. Paraffinoma/Foreign Hydrocarbon injection [Favored]:
Supported by: 1. age, sex, and location not inconsistent. 2. Superficial bias in the dermis might suggest a timid injection attempt, likely self-inflicted. 3. Absence of obvious atypical/malignant cells.

2. Well-differentiated inflammatory liposarcoma: 1. absence of classic multinucleated foreign body histiocytes despite a chronicity implied by the plasma cell infiltrate and follicular changes. 2. Unusual small clear cells with central nuclei, small and large signet cells, and physaliferous cells with hyperchromatic/indented nuclei (top right quadrant center in Picture #3) are of greatest interest in this context. But cutaneous LS is a rare zebra of a diagnosis, and is opposed by all reasons given in support of foreign hydrocarbon injection.

I would follow up with: S100 immunostain, and polarized light exam of slide [sometimes but not always positive for refractile material in foreign body injection]. Also, a clinical history check for onset details may be the most useful ancillary ‘test’ (although patients often deny hydrocarbon injections).

Hi, this is a difficult case without the clinical information. It is a biopsy from an injection site that developed a reaction. I thought that it was nice to include this case as one does not often see the phenomenon.

Looks like silicone injection. Is it known the substance that was injected?

An excellent review about this issue was carried out by Dadzie OE et cols. Adverse cutaneous reactions to soft tissue fillers --- a review of the histological features. J Cutan Pathol 2008;35(6):536-548.

Thank you Dr. Rocha, and many thanks to my dear friend Ophelia for writing a such beatiful review.

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