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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 928 - 13th January 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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The patient is a 45 year old woman with a punch biopsy taken from the left middle finger over the PIP knuckle.

Case posted by Dr. Mark Hurt


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I see diminished elastic fibers in a background of sparse cellular inflammation. My first hypothesis was Acrokeratoelastoidosis, but this is typically seen over the margins of the hands and feet. I also think this could be a late stage if Granuloma annulare.

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Eman El-Nabarawy

Posted

Degenerative collagenous plaques of the hands vs acrokeratoelastoidosis presenting as knuckle padlike lesions (as a part of marginal papular acrokeratoderma disorders).

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Guest Tiberiu Tebeica

Posted

The first impression I had looking at the low power picture was nephrogenis systemic fibrosis, but taking into account the clinical information and the special stains, I think acrokeratoelastoidosis fits best. There is a case of acrokeratoelastoidosis described in literature, which presented clinically as [url="http://www.ncbi.nlm.nih.gov/pubmed/?term=3891801"]small papules located mainly over the interphalangeal joints[/url].

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Guest Maria George

Posted

ITo e there is mcinous degeneration.Could be surface of synviial cyst , i.e mucus cyst .I would order deeeeep secttion.

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Robledo F. Rocha

Posted

Acrokeratoelastoidosis is a genodermatotic keratoderma and, as such, I would expect to find hyperkeratosis overlying a slightly pushed-down epidermis. To me, stratum corneum appears normal for an acral site. Furthermore, the basophilic fragmented elastic fibers are too deep located and escorted by interstitial histiocytes immersed in increased connective tissue mucin, findings that suggest subcutaneous granuloma annulare.

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Guest Jim Davie MD

Posted

I agree with Maria and Robledo. There is some raggedness at the lower edge that may suggest a synovial cyst edge, and there is increased dermal mucin. Synovial cyst vs. GA.

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Guest Mazen charaf iddin

Posted

[right][font="arial, verdana, tahoma, sans-serif"][color="#1c2837"][size=4]I agree with Dr. Robledo F. Rocha for the epidermal changes, and the lesion is deeper than [/size][/color][/font][/right][color=#1C2837][font=arial, verdana, tahoma, sans-serif][size=4]acrokeratoelastoidosis.[/size][/font][/color][right][font="arial, verdana, tahoma, sans-serif"][color="#1c2837"][size=4] If it's only one lesion, I'll considered it a resolving (fibrotic, [/size][/color][/font][/right]scarred ) [color=#1C2837][font=arial, verdana, tahoma, sans-serif][size=4][right]fibrous histiocytoma ( giant cell tumor of tendon sheath) with degenrative changes in nucli of fibroblast. Nuclear changes like this [/right][/size][/font][/color]aren't[color=#1C2837][font=arial, verdana, tahoma, sans-serif][size=4][right] seen in [/right][/size][/font][/color][color=#1C2837][font=arial, verdana, tahoma, sans-serif][size=4]acrokeratoelastoidosis[/size][/font][/color]

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Mark A. Hurt MD

Posted

Thanks, everyone for your comments today. I had gone through these as part of the differential diagnosis before writing my report. Another piece of clinical information, which I withheld for the purposes of this exercise, was that the clinical diagnosis was knuckle pad.

Here is my diagnosis and comment:

[b]-- KNUCKLE PAD[/b]
[b]COMMENT: [/b]Knuckle pads can have a spectrum of findings including fibromatosis-like, hyperkeratosis-like, and "swollen" collagen fibers, the latter of which this specific example appears to emulate. Given the history of the patient having fibromatosis in the feet in 2004, I suspect that this current lesion may be commensurate with the fibromatosis-like pattern in this patient.

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