Case Number : Case 1426- 10 December Posted By: Guest

What about granulomatous variant of pigmented purpuric dermatosis as a differential? the clinical history doesnt match but the histology made me think of it. There is a variant of sarcoidosis mimicking PPD also.

P/s: The last picture is not working

Argee, my first thought. Granulomatous PPD. There have been several reports of it in the last years.

Granulomatous drug reaction. 

As Raul and Igor, my first thought was granulomatous PPD, extension outside lower limbs is rare but can occur. My other thought was granulomatous drug reaction as Abdul-Kadir suggested. I think PPD like sarcoidosis referes to a clinical presentation mimicking PPD and a pathological picture typical of sarcoidosis.

I'm thinking about some extra intestinal localization of Crohn disease, but i've never seen it!

I see some neutrophils and nuclear dust. I am thinking of erythema elevatum diutinum.

The first thought is often the best thought!... Yes, this is a case of granulomatous PPD with a combination of capillaritis and granulomata. It can be tricky on images, but I can confirm that there were no neutrophils in the section. The clinical presentation was of a purpuric rash with PPD as the main clinical consideration. Unfortunately, the original report by an outside pathologist focused only on the granuloma and patient had several investigations to rule out an infective eitiology. I think if one is not aware of this entity, it is easy to be misled. There have been several reports of this distinct entity with many showing an association with hyperlipedemia. The widespread nature was certainly unusual but has been described, as Mona rightly said. Thanks for the great discussion!