Case Number : Case 1033 - 9th June Posted By: Guest

Urticarial vasculitis.
Other things to be mentioed are other causes of vasculopathy such as DIC , cryoglobulinemia......etc.

Indeterminate leprosy.

Agree that histology is certainly suggestive of urticarial vasculitis. Ofcourse, needs correlation with clinical presentation[b].[/b]

Urticaria-like lesion. I do not see vasculitis.

c/w late-stage leucocytoclastic vasculitis (LCV). The prominent orange pink deposits raise cryoglobulins or other coagulopathy in the differential. Cryoglobulins can cause LCV.

[quote name='Dr. Richard Carr' timestamp='1402325960']
c/w late-stage leucocytoclastic vasculitis (LCV). The prominent orange pink deposits raise cryoglobulins or other coagulopathy in the differential. Cryoglobulins can cause LCV.
[/quote]

Agree with Richard...LCV vs. cryoglobulinemia. This neutrophil-rich sparse perivascular lymphocytic infiltrate has variably degraded neutrophils and leukocytoclastic debris, with extravasated red cells. Vessels show equivocal fibrinoid changes with some apparently plugged with eosinophilic material (which may be either packed RBCs vs. cryoglobulin on these images). Eosinophils are notable for their absence. No epidermal changes.
I would imagine the DIF was ordered for a differential of vasculitis vs. urticaria.

This was somewhat difficult to photograph, but there is granular IgA in vessels.

MAH

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE1033_Image%2007.jpg[/img]

The presence of sparse perivascular infiltrate with neutrophilic karyorrhexis, small number of extravasated erythrocytes and slight dermal edema, and the lack of both fibrin in vessel walls and thrombi within lumina, make me think of early leukocytoclastic vasculitis. Granular deposits of IgA in vessels suggest Henoch-Schönlein purpura in a rare clinical presentation in the upper extremity of an old adult.
The so-called urticarial vasculitis is nothing more than an early leukocytoclastic vasculitis which expresses itself clinically as edematous urticarial papules due to paucity of extravasated erythrocytes.

Old lesion of LCV vasculitis, IgA mediated. Strange age for Henoch Schonlein as Robledo said.

I agree with HSP, based on the IMF.

Here is the follow-up (click the [url="https://dermpathpro.com/spot-diagnosis-1/_/free-spot-diagnosis-june-2014/june-2014/case-1029-3rd-june-r1069"]hyperlink[/url]) to my case from last [url="https://dermpathpro.com/spot-diagnosis-1/_/free-spot-diagnosis-june-2014/june-2014/case-1029-3rd-june-r1069"]Tuesday[/url], June 3rd.

On the case for today (above photos), here is the initial report I wrote:

SKIN, LEFT MID POSTERIOR UPPER ARM , PUNCH BIOPSY :
[b]-- ALLERGIC URTICARIAL REACTION[/b]
[b]COMMENT:[/b] The findings suggest a hypersensitivity reaction. While there is no evidence of vasculitis, some early vasculitic processes may exhibit similar findings. Drug reactions, urticaria, insect bites, and bullous pemphigoid may, at times, have similar morphologic findings.


About 2 weeks later, I received the DIF, which contained the granular IgA. My report was as follows:

SKIN, RIGHT ULNAR MID VOLAR FOREARM , BIOPSY FOR DIRECT IF :
[b]-- IgA AND C3 GRANULAR VASCULAR DEPOSITION[/b]
[b]COMMENT: [/b]These findings are compatible with an IgA mediated vasculitis. Reviewing the immediate prior, the specimen did not, technically, meet the criteria for vasculitis, but there is leukocytoclasis and the cellular constituents are neutrophils and eosinophils, so it is within the spectrum of perhaps an incipient vasculitis even though I am unable to diagnose vasculitis definitively on that prior.

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I think that Richard's and Jim's comments are also useful in this case. If I learn more, I'll pass it on.

MAH