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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 1063 - 21st July 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 79 year old white woman with a history of pruritic, vesicular bulbous lesions on the arms, legs and trunk. Punch biopsies for H&E microscopy and direct immunofluorescence of the areas near the papules are taken from A and B - the peri-lesional skin.

Case posted by Dr. Mark Hurt


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Dr. Mona Abdel-Halim

Posted

Since there is no history of mucous membrane affection, I will call it bullous erythema multiforme.

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Interface dermatitis with extensive epidermal necrosis. It can be either EM or SJ/TEN, cutaneous clinical picture is important. I think clinically, the DDx should have been BP.

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Dr. Richard Carr

Posted

Very "inflammatory" for EM / TEN but the nice basket weave keratin (of an eruptive dermatosis) would support. Also consider paraneoplastic pemphigus (EM-like pattern) and PLEVA and Rowell's syndrome (deeper infiltrate lupus like). Purely on histology with some odd cytopathic nuclear changes would also have considered herpes / zoster group.

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Mark A. Hurt MD

Posted

Here IHC stains. No DIF was submitted.

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE1063_Image%2005.jpg[/img]

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE1063_Image%2006.jpg[/img]

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE1063_Image%2007.jpg[/img]

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE1063_Image%2008.jpg[/img]

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Robledo F. Rocha

Posted

Erythema multiforme herpeticum due to extensive epidermal necrosis with preservation of the basket weave pattern of the stratum corneum. Cytopathic effect suggestive of herpesvirus infection is now highlighted by immunostains.

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Uma Sundram

Posted

Agreed, herpetic dermatitis. When you go back to the highest power micrograph, there is a cell demonstrating viropathic effects.

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Mark A. Hurt MD

Posted

I spoke too soon; DIF was performed, and it was negative.

My diagnosis was:

[center]A.[/center]

SKIN, PERI-LESIONAL , PUNCH BIOPSY :

[b]-- HERPES (consistent with)[/b]
[indent=1][b]COMMENT:[/b] I say "consistent with" because I think that the epidermis is necrotic enough that I am unable to identify the "classical" cytopatopathological effect, but there is a strong suggestion that some of these "ghost" nuclei are multinucleated like the nuclei of Herpes. Further, the presence of IHC positivity for Herpes I and II also supports the diagnosis of Herpes infection. I don't identify any VZV or CMV by IHC. I don't identify evidence to support allergic dermatitis or pemphigoid or dermatitis herpetiformis. For definitive confirmation, it might be of some value to obtain PCR (which we do not perform in our laboratory) or a biopsy of an evolving "early" lesion. Correlation is suggested.[/indent]

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