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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 841 - 6th September 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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6 years old female. Barely visible pale plaques on torso.

Case posted by Dr. Richard Carr.


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Wolter Mooi

Posted

I would be interested in an elastin stain. The pictures remind me of elastoma / Buschke-Ollendorf syndrome. But I have never diagnosed that lesion before :)

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guttate morphea

the fibroblasts that synthesize mucin ( can be seen in morphea) is visible between the thickened eosinophilic hylanized collagen bundles more prominant at the junction between the reticular dermis and fat tissue is typically seen.

There is mild superficial perivasualr lymphocystic infiltrate in the papillary dermis with normal epidermis
hair follicles and seb glands not seen in the center of the lesion, only the arrector pilorum is left alone

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Guest Engin Sezer

Posted

Sclerosis of deep dermis with mucin deposition between the collagen bundles suggestive of incipient morphoea

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Guest Maria George

Posted

While the fenestrations of the collagen fibers by mucin point toward a type of cutaneous mucinoses such as (sclerema, scleromyxedema , lupus, REM, ..etc), the combination of superficial perivascular infiltrate with mucin in between collagen make me think for sure that this is a case of Granuloma annulare.

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Guest Jim Davie MD

Posted

Connective tissue nevus (shagreen patch).

There is sometimes slight increase in fibroblasts and interstitial mucin in these lesions.
I don't see any elastin fibers in the high-power image (unless they are staining red), although an elastin stain would be the gold standard to help support the diagnosis.

The differential diagnosis would be tuberous sclerosis or (as Wolter said) Buschke-Ollendorff syndrome.
I favor tuberous sclerosis if the patches were discovered in childhood rather than postnatally, although the absence of other TS findings would favor BOS.

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Robledo F. Rocha

Posted

I opine for late morphea. Inflammatory infiltrate is less than scant and diminished plump fibroblasts can be found in the midst of thickened collagen bundles with increased mucin between them.

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Dr. Richard Carr

Posted

Well done Wolter!!! These are I believe elastomas of Buschke-Ollendorff. Thickened hyaline elastic fibres in zonal areas of chicken wire appearances around the collagen. Giving the elastic stain would make it far too easy for this crowd but I was a little surprised but the responses. Jim - sorry the elastic fibres are a bit red in these images. You also need to watch out for the haematoxylin in Warwick which exaggerates any hint of interstitial mucin especially the day after the stains are changed!!

I have to thank Dr Vivek Mudaliar for kindly sharing this case with me.
Enjoy your weekends

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As a clinician, I would like to point out that stretching the skin helps in visualising the elastomas of Buschke-Ollendorf syndrome.

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