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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 1167- 12th 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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M48. Buttock. Intensely itchy vesicles. Elbows, knees, buttocks. ?DH

Case Posted by Dr.Richard Carr


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Analyzing only figure 7 there´s a subepidermal cleft rich in neutrophils that can be part of a picture of DH. In fact, DH seems a nice hypothesis clinically, as it afects extensor surfaces and is very itchy. But I am having some difficulties about the follicular based inflamation with pustules. I looked for HSV inclusions, but did not find it. I do not know exactly what is this case and I am very curious.

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Dr. Mona Abdel-Halim

Posted

I am exactly feeling like you Igor!!!! I guess this is DH with secondary staph folliculitis secondary to the severe itching...

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Mark A. Hurt MD

Posted

Neutrophilic infundibulofolliculitis. I favor infectious. What about hot-tub folliculitis?

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Pustular folliculitis. The distribution made me favour a systemic disease, e.g. a pustular drug reaction, Crohn's, Reiter's, Behcet's, etc., as opposed to an infection. I probably would not have thought of dermatitis herpetiformis had it not been mentioned.

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Guest Romualdo

Posted

Agree with Igor: there are foci (Figure 7 and left side of Figure 4) resembling dermatitis herpetiformis. Like Mona I also think this is DH with secondary folliculitis.

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Sasi Attili

Posted

Agree with all the differentials. Tough one to crack on H&E alone. Would be requesting DIF on this one!

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Dr. Richard Carr

Posted

I reported this as pustular folliculitis but the clinical was a clear-cut case of DH and in fact the patient had typical serology and DIF for dermatitis herpetiformis. I wonder if the biopsy is indeed showing both pathologies as some of you pointed out. The lesson for the clinical colleague is not to dismiss the clinical diagnosis based on an aberrant histology (not matter who the name on the report). The lesson for the pathologist is not to dismiss the clinical diagnosis even if the histology is not quite right. In this case the suppurative folliculitis may be an incidental finding, all be it one that is dominating the histology in this particular biopsy.

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Sasi Attili

Posted

Thanks Richard. I completely agree. Most of the cases I see here in India are inflammatory and I have hardly seen a 'typical' inflammatory disease since starting practice here 8 months ago!. CPC is very important and it is very important to re-learn the histology from the clinical! Diseases do not read textbooks....

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