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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 1524 - 27 April 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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60/M with a symmetrical erythematous rash in groins, upper thigh and axilla (started nearly 20 years ago). Flares up every 6-12 months, sore and occasionally itchy. Clinical d/d- ?erythrasma, ?eczema.
2 biopsies, 1st punch bx , from axilla, done in 2013 (images 1-4) and 2nd incisional bx from thigh, 2014 (images 5-10). Image 9- CD4, image 10- CD8

Case posted by Dr Arti Bakshi


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Nitin Khirwadkar

Posted

The first 4 images and the next four as well are very PPD like. However, there is definite lymphocyte atypia in the second set, but rather focal tagging. CD4s>>CD8s. Agree with Raul, purpuric Mycosis fungoides. Was the patient applying steroids?

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vincenzo polizzi

Posted

Difficult case...I don't see any definite lymphocyte atypia, not even a convincing junctional lymphocytic spreading, but i agree that a PPD-like MF fits clinically perfectly. I can't wait to know the diagnosis.

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Arti Bakshi

Posted

Yes, Vincenzo, this is a difficult one. Cant say that I have a firm diagnosis either and I put it in more for discussion's sake. 

Purpuric MF was my concern too, but clinically the rash comes and goes and can settle spontaneously without steroids. The biopsies were done in 2013/14 and at the last clinic a couple of weeks ago, his rash had not progressed at all (has not been on any treatment for some time). The CD4:CD8 ratio is skewed, but this can occur in many inflammatory states too. TCRPCR did not show clonality.

Given the distribution of lesions, any other suggestions? (will leave the case for another day)

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Nitin Khirwadkar

Posted

Was the patient on any drugs? SDRIFE???? Not sure, tricky case indeed!

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Raul Perret

Posted

As nitin suggested, the other diagnosis that could fit  is sdrife or baboon syndrome but recurring and for many years? i cannot make this fit. I was considering atypical case of PPD or maybe itching púrpura that can be recurring and affect the folds but is difficult to assure 100% the diagnosis.

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vincenzo polizzi

Posted

The SDRIFE fits very well with clinic history but is a perivascular dermatitis with eosinophils and lymphocytes histologically, not at all a purpuric, lichen aureus-like infiltrate....

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Nitin Khirwadkar

Posted

Yes, I know. Thought that the vascular injury is secondary to a drug, although the rest of histology associated with SDRIFE is not present. Could this be some kind of contact dermatitis??? Not a great deal of spongiosis though. 

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Arti Bakshi

Posted

Thanks for all your comments. As I said, there is no firm bottom line here but I think you all have covered the entire d/d pretty well!

Babboon syndrome or SDRIFE did fit well with the clinical description and distribution of rash, but there was no relevant drug history. The course of the disease was gainst Purpuric MF. An atypical presentation of PPD still likley, I suppose, but a really odd distribution and disease course. 

This leaves the possibility of a purpuric contact dermatitis, which on balance, is the best fit. Purpuric contact dermatitis can occur following exposure to a variety of allergens, including, textile dyes, rubber, components of washing powdres etc, which may explain distribution in areas with tight fitting of clothing. At the CPC meeting, a decision was taken to patch test and I await the results. I also took a second opinion from Dr Calonje and he pretty much rasied the the same d/d as considered above, but favoured purpuric contact dermatitis.

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Raul Perret

Posted

Thanks for all your comments. As I said, there is no firm bottom line here but I think you all have covered the entire d/d pretty well!

Babboon syndrome or SDRIFE did fit well with the clinical description and distribution of rash, but there was no relevant drug history. The course of the disease was gainst Purpuric MF. An atypical presentation of PPD still likley, I suppose, but a really odd distribution and disease course. 

This leaves the possibility of a purpuric contact dermatitis, which on balance, is the best fit. Purpuric contact dermatitis can occur following exposure to a variety of allergens, including, textile dyes, rubber, components of washing powdres etc, which may explain distribution in areas with tight fitting of clothing. At the CPC meeting, a decision was taken to patch test and I await the results. I also took a second opinion from Dr Calonje and he pretty much rasied the the same d/d as considered above, but favoured purpuric contact dermatitis.

Nice case Arti, could you keep us informed on the results of the patch test?  

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