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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 942 - 31st January Posted By: Guest

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
Submitted Date :
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M72. Thumb. ?Inclusion cyst

Case posted by Dr. Richard Carr.


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Guest Maria George

Posted

Foreign body by a plant thorn with superadded nocardia and other bacteria.

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Guest Tiberiu Tebeica

Posted

Abscess determined by an infected splinter.

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Dr. Mona Abdel-Halim

Posted

Agree, infected foreign body granulomatous reaction

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Guest Romualdo

Posted

[quote name='Guest' timestamp='1391165936']
Foreign body by a plant thorn with superadded nocardia and other bacteria.
[/quote]
Besides a plant thorn it could be a splinter of wood. Faraco's stain should be positive in nocardiosis, too.

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Dr. Richard Carr

Posted

The special stain is a PAS. I have asked the dermpathpro team to post a couple more special images for your interest.

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Mark A. Hurt MD

Posted

Definitely a thorn in this thumb. Thus far, I'm no better off with the PAS.

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Dr. Richard Carr

Posted

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE942_RAC6688x10_Polar.jpg[/img]

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE942_RAC6688x60_Gram.jpg[/img]

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Eman El-Nabarawy

Posted

Nocardiosis (primary cutaneous) secondary to trauma by foreign body.

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Dr. Mona Abdel-Halim

Posted

Nocardia is the infectious organism with this foreign body,,,

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Robledo F. Rocha

Posted

Nocardiosis secondary to splinter trauma.

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Guest Jim Davie MD

Posted

This is a nice case!
1. Wood splinter given the parallel arrays of tubules (xylem), with fibrosis and plasma-cell rich inflammatory reaction.
2. Actinomycete infection (very likely Nocardia spp., given extensive branching of the filaments).
I think the images show a subtle beaded Gram+ pattern on Gram stain that is common to see for the actinomycetes like Nocardia.

(Example: Gram stain image with beaded pattern: [url="http://http://path.upmc.edu/cases/case226/images/micro15.jpg"] http://path.upmc.edu/cases/case226/images/micro15.jpg[/url] ).
[img]http://path.upmc.edu/cases/case226/images/micro15.jpg[/img]

[i]This is taken from an educational case report of systemic Nocardia infection (from my alma mater, University of Pittsburgh). It has a brief discussion of Nocardia and related actinomycete staining properties and identification, including possibility of misleading false-negative staining for Gram and modified AFB stains:[/i]
[i] Case Discussion: [url="http://path.upmc.edu/cases/case226/dx.html"]http://path.upmc.edu...ase226/dx.html[/url][/i]
[i] Case Report: [url="http://A%2075%20Year%20Old%20Female%20with%20Bilateral%20Pneumonia"] [/url][/i][url="http://path.upmc.edu/cases/case226.html"][size=4]A 75 Year Old Female with Bilateral Pneumonia[/size][/url]

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Dr. Richard Carr

Posted

Thank you so much for the contributions. I reported this as a splinter with filamentous bacteria (actinomyces-like). I have always thought histology for bacteria can only take us so far and seems reading Jim's very helpful case discussion that was right! I will ask for the Gram stain to come back and photograph it under oil to see if I can see the beading but suspect not as I was aware of Nocardia doing that. I have seen very few cases (that I was aware of) of culture confirmed cutaneous nocardiosis.

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Dr. Richard Carr

Posted

Re-examined under oil and I am not convinced much beading. Unfortunately area cut-out so Faraco-Fite stain unhelpful.

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