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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 1182 - 2nd 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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F58. Rheumatoid arthritis. Indurated skin lesion / lump right breast. Also has Diabetes. Punch biopsy in breast clinic.

Case posted by Dr Richard Carr


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Robledo F. Rocha

Posted

Morphea. Beautiful [url="https://dermpathpro.com/index.html/_/latest-news/perineural-in%EF%AC%82ammation-in-morphea-r52"]perineural inflammation[/url].

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Mark A. Hurt MD

Posted

I also favor morphea, but I did consider NLD because of the "zig-zag" pattern of inflammation and the many plasma cells.

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Sasi Attili

Posted

Beautiful case. Favour inflammatory morphoea

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Dr. Richard Carr

Posted

Good responses and I agreed with the majority of inflammatory morphoea, my report as follows:

Many thanks for asking me to review this fascinating biopsy. The upper
dermis shows relatively mild perivascular lymphocytic and plasma cell
infiltrate. The striking feature is in the lower two-thirds of the
dermis, which is markedly expanded and has a mixed perivascular and
interstitial infiltrate of lymphocytes, histiocytes and numerous plasma
cells. Eosinophils are relatively sparse. I interpreted the collagen
bundles as being rather swollen and highly suggestive that this is a
case of inflammatory morphea. The differential would include Lupus
Profundus, although mucin is lacking. I think it would be prudent to
exclude Lyme Borreliosis, but histologically this appearance is very
good for the severe inflammatory (almost pseudolymphomatous) end of the
spectrum of morphea.

I agree the biopsy does have a zig-zag like appearance but I thought the lack of convincing necrobiosis and lack of palisading histiocytes or well formed granulomas as well as the clinical location argued strongly against necrobiosis lipoidica compared with morphoea and thefore did not mention this differential in my opinion but I think from the histolgoical perspective it is a good consideration. Regarding nerve involvement I was aware from two unpublished cases presented by Dr Eduardo Calonje that this could be a striking feature of morphoea (hence I focussed down on it in this case) but I was not aware this had been published so thanks to Robledo.

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