Case Number : Case 1715 - 23 December - Dr Richard A Carr Posted By: Guest

Your pre-festive week is nicely rounded off with a neat case from Dr Richard A Carr

Geoff Cross - DermpathPRO Projects

On my cell phone screen, looks like gouty tophus.

Merry Christmas to all of my DermpathPRO colleagues!

For me it looks line a necrotizing granulomatous reaction to discard in first place infectious (tbc, leishmania etc.) and if negative also in culture start considering rheumatoid nodule and necrotizing sarcoidosis and other rarer entities. That said I find that the dx of gout based on pictures is rather confusing sometimes (at least for me). Wish you all guys and the team of dermpathpro a Merry christmas!

What about LMDF??

Christmas Eve will be in the weekend, so Merry Christmas everybody.. wish u all happy holidays.

My first thought was LMDF as well. But only after performing special stais for microorganisms.

Merry Christmas!!! Hope to meet you all someday!

Merry Christmas dear Colleagues and thanks for your pleasant company in this amazing website.  

It's a granuloma with some fissures and clefts gouty like. But not sure. 

What about a filler cosmetic granuloma?

I also thought of LMDF (lupus miliaris disseminatus faciei) but the only case I have seen in a presentation was as multiple papules and I thought the clinical picture looked more like a single isolated lesion.

Favour gouty tophus....unusual site but described.

Merry christmas to all!!

Here is your Diagnosis: Granuloma, caseous (acne agminata-like lesion).

Merry Christmas - Richard

I am too late today. Lovely case.

Merry Christmas everyone.

Thanks for the nice case.

Merry christmas to you all.

have a nice holiday guys!

why did you favour acne agminate-like  granuloma over gouty tophous

and why we didnot think of caseating granuloma like tuberculosis

Thanks for the question.  Interestingly I did not even consider gout although I can see why you might as we do have a pink substance with macrophage response.  In gout (see case 1665) the delicate ghosted crystalline outlines can usually be appreciated, as slender rays in the matrix, and the granulomatous peripheral reaction is usually purely histiocytic i.e. lacking the prominent lymphocytic infiltrate of a tuberculoid (casesous) granuloma seen here. It seems the histopathology of acne agminata (AKA lupus miliaris disseminates facei) is pretty rarely described.  In this case I thought it showed the typical histology but as it was sent as a solitary lesion I referred to it as acne agminata-like lesion (assumed a reaction to a ruptured pilosebaceous unit in the delicate skin of the eyelid). The clinician will have to correlate to see if the patient has other lesions etc.  I prefer acne agminata to the longer name as I am not good with long names and in this instance it's awfully confusing!  I did not do special stains because it was a solitary lesion (and lacks suppuration) but I can imagine in other parts of the world where TB is more prevalent one probably would.