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In this section we have spot diagnoses posted on a daily basis since June 2010, now over 4000! You can review the archived cases and read the suggested diagnoses by users and the final comment by the contributors.
Case are uploaded each week day by 10 am UK time with the correct diagnosis will generally be posted at 8 pm UK time. Why not view the most recent spot diagnosis and proffer a diagnosis?

Case Number : Case 1352 - 28 August 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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F50. Vasculitic rash with large bilateral symmetrical nodules on the hands, feet, ankles, shins and knees. ?EED, ?lymphoma, ?sarcoidosis
Case courtesy of Dr Arti Bakshi

Case posted by Dr Richard Carr


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Dr. Mona Abdel-Halim

Posted

I think we have foci of necrobiosis associated with interstitial histiocytes, mucin deposition in addition to the neutrophilic infiltrate, with few esinophils. Pathologically, I think it fits with palisaded neutrophilic and granulomatous dermatitis (interstitial granulomatous dermatitis). Clinically we have a vasculitic rash together with large nodules (distribution similar to rheumatoid nodules, rheumatoid nodules like). I do not know from where the biopsy was taken but the pathology to me fits with palisaded neutrophilic and granulomatous dermatitis. I think the case needs extensive work up for the possibility of an underlying systemic disease: RA, LE, Sjogren, Wegner's, Churg Strauss etc....

The clinical description of the large symmetrical nodules fits with EED but I do not expect a vasculitic rash in such cases. Pathologically, I can not explain the necrobiotic foci with mucin in the last four images in the context of EED and I do not see evident vasculitis.

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Eman El-Nabarawy

Posted

What about Erythema elavatum diutinum mimicking palisaded neutrophilic and granulomatous dermatitis pathologically?
The clinical picture of large nodular lesions on acral sites favored EED while the pathological features are in consistent with palisaded neutrophilic and granulomatous dermatitis!! On searching, I found a case of erythema elavatum diutinum present with overlapping pathological features of palisaded neutrophilic and granulomatous dermatitis.
http://www.ncbi.nlm.nih.gov/pubmed/?term=Erythema+elevating+diutinum+AND+palisades+neutrophilic+granulomatous+dermatitis#

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Guest Romualdo

Posted

Agree with palisaded neutrophilic and granulomatous dermatitis.

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Dr. Richard Carr

Posted

Excellent discussion.
I called this palisaded and neutrophilic and granulomatous dermatitis when Arti showed me the sections but made the following remarks having seen the clinical images:

"Yes I agree clinically this looks like EED and not palisaded neutrophilic dermatosis.
Histologically it has many similarities too with leucocytoclasis (suggest you read Weedon!). Weedon even mentions cases of EED with necrotising granuloma and basophilic collagen degeneration. You might do a Perl’s stain to look for iron which can be seen in the chronic leucocytoclastic vasculitides. The chronic fibrosclerosing changes of late EED are lacking. So it is probably EED based on clinical appearances showing histological similarities to palisaded neutrophilic dermatosis!
Great case. Regards Richard"

There was no underlying systemic disorder and he was otherwise fit and well.

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Arti Bakshi

Posted

Thanks Dr Carr for helping me with this case and to all others for their excellent input. Just a bit of feedback. Perls was negative in this bx, but another bx was done from a more macular area which showed good going changes of vasculitis.
patient was started on dapsone and the lesions have melted away!!

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