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Case Number : Case 1202 - 30th January 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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M31. Left palm biopsy. 3y well demarcated hyperkeratotic plaques on left palm and erythematous papules on left wrist and right shin. No nail psoriasis. DD: Psoriasis, eczema, CTCL

Case posted by Dr Richard Carr


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Dr. Mona Abdel-Halim

Posted

I did not perceive the lymphocytes within the epidermis as malignant. I also see evident spongiosis mainly in the lower epidermis with stellate and elongated keratinocytes and vesicles. Parakeratosis with neutrophils. Areas of supra papillary thinning and some dilated capillaries. I think this is psoriasis, which on the palms and soles can be very difficult to differentiate from Eczema.

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Guest Romualdo

Posted

Agree with Mona. Almost all lymphocytes are located within dermal papillae. The ones within the epidermis are of the same size as dermal lymphocytes and do not look overtly malignant. Marked spongiosis militates against mycosis fungoides. I think this is psoriasis.

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Eman El-Nabarawy

Posted

Although many features are suggestive of psoriasis, hypergranulosis and atypical lymphocytes make me favor MF.

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Mark A. Hurt MD

Posted

I favor spongiotic dermatitis. I would probably work it up with MF in mind, but I don't think it is MF. The lymphocytes are small and occur mostly in zones of spongiosis. I also doubt psoriasis, as there is marked granulosis, and the cornified layer doesn't look like a psoriatic scale. I would also need to do a PAS to exclude fungus.

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Dr. Richard Carr

Posted

Thanks Mark. I did not work it up for MF but I had the advantage of a second biopsy from the wrist that also favoured eczema. Although I think even in the palmar biopsy I favoured eczematous dermatitis for the exact reasons highlighted perfectly by Mark. My report as follows:

A and B Eczematous reaction pattern with fairly dense superficial perivascular lymphocytic infiltrate. Eosinophils not notable. No lymphoid atypia. No fungi (PAS).

I was then asked a specific question from the clinical colleague as follows: "Could this be hyperkeratotic palmar eczema?"

My supplementary report as follows:
[size=3][color=#000000]Thank you for asking me to re-visit the specimens. There is a description in Weedon’s textbook (“hyperkeratotic dermatitis of the palms”) that matches perfectly with that seen in this case (prominent spongiosis, dense lymphocytic infiltrate with prominent exocytosis). There is quite a bit of parakeratosis in the palmar biopsy but the relatively preserved or thickened granular layer and degree of spongiosis led me to favour an eczematous dermatitis in this biopsy rather than psoriasis although the latter distinction can be exceedingly difficult in acral biopsies. The features in the biopsy from the wrist also favoured an eczematous dermatatitis rather than psoriasis.[/color][/size]

[size=4][color=#000000]Additional remarks: Agree about knee-jerk of doing PAS for fungi in eczematous reactions generally and especially localised lesions including particular anatomic locations (feet, hands, flexures and moist areas).[/color][/size]

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