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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 1228 - 09 March 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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The patient is a 6 year old white boy with crusted papules on the trunk and limbs, present for a few years, taken from the right abdomen.

Case posted by Dr Mark Hurt


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biswanath behera

Posted

[b]
[size=3]scale crust, keratinocyte pallor, collection of Langerhan's cells in epidermis, necrotic keratinocytes, upper dermal lymphohistiocytic infiltrate, wiry collagen......Langerhans' cell histiocytosis????[/size][/b]

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Mark A. Hurt MD

Posted

Good thought. Let's see if we can expand the differential.

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Dr. Mona Abdel-Halim

Posted

Pityriasis lichenoides

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Mark A. Hurt MD

Posted

I'm going to do one more IHC stain on this lesion, so I'll probably have to report this on Tuesday, the 10th. Meanwhile, keep expanding the differential, if you can. I like what I'm seeing so far.

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Dr. Mona Abdel-Halim

Posted

Considering the wiry fibroplasia, I would like to add also in the DDx: papular MF but I think reported cases were not described as crusted but still I think it is worth considering. OR, type B LyP which will fit more with the crusted nature of the papules.

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Arti Bakshi

Posted

Will go with pityriasis lichenoides. (combination of spongiosis, marked lymphocytic exocytosis and dyskeratosis).
LCH less likely as no eosinophils…., but need immunos!

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Guest Romualdo

Posted

I agree with Mona and also think this is PLEVA (Mucha-Habermann disease) with associated Langerhans' cell microabscesses.

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Dr. Richard Carr

Posted

I struggled with this one a lot this morning. Interesting clustered dyskeratotic cells and slightly epidermotropic lymphocytes. I don't think it is LCH as these look like reactive Langerhan's cells to me. My first consideration is pityriasis lichenoides with the other differentials (Type B Lyp and papular MF less likely but requiring clinpath correlation and follow-up to rule out). Nice images.

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Guest Tiberiu Tebeica

Posted

My first tought is PLEVA (Mucha-Habermann disease). I would consider type D LyP in the ddx, so curious to see if all the intraepidermal lymphocytes are positive for CD8. Anyway, since usually PLEVA shows a CD8+ phenotype, how could one reliably differentiate between these two entities? I don't favor LyP because I don't see enough pagetoid spread of lymphocytes and atypical lymphoid cells, but these are subjective criteria. Moreover, there is plenty of apoptotic keratinocytes, usually present in PLEVA and absent in LyP.

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Pityriasis lichenoides seems to be the best fit, histologically. But this is a relapsing-remitting disease and the lesions are papulosquamous ("chronic") and/or papulonecrotic ("acute"), neither of which is reflected in the history.

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Mark A. Hurt MD

Posted

Thanks, everyone, for all of your insights. I am waiting on one more marker, then I'll report my diagnosis.

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Mark A. Hurt MD

Posted

My diagnosis was Mucha-Habermann disease (PLEVA). Clinically, it was thought to be PLC, psoriasis, or "other". It isn't psoriasis, clearly. I thought PLEVA was the best fit clinicopathologically. I originally obtained markers for MF, but nothing unusual emerged; CD30 was negative, also. I obtained CD1a yesterday, and it is negative.

Thanks, everyone.

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