Case Number : Case 1477 -22 February Posted By: Guest

xanthoma (flat xanthoma?) Dyslipidemia should be ruled out.

Palisaded granulomatous collection of  Touton, foamy-cells and cholesterol clefting, with necrobiotic collagen. I favour Necrobiotic Xanthogranuloma. Paraproteinemia?

Xanthogranuloma. Pondered about a lipidised DF (although not typical) and a cholesterol granuloma.

To be honest necrobiotic collagen is not readily apparent to my eyes and the biopsy is quite superficial (we dont see the hypodermis). I would be scared to diagnose necrobiotic xanthogranuloma in this case only based on histology

Site typical for necrobiosis lipoidica. Histo more suggestive of NXG

Agree with Sasi that the site is suggestive of necrobiosis lipoidica. (as also presence of dermal fibrosis in a layered pattern).

Apparently one can get cholestrol clefts in necrobiosis lipoidica rarely http://www.ncbi.nlm.nih.gov/pubmed/3351060

Ofcourse clinical correlation is essential

NLD

Yes, the cholesterol clefts aren't strictly clues to NXG, because of rare occurrence in NLD, implicating diabetes mellitus with complications...but in img2 and img3 there are atypical and Touton type giant cells, so typical for NXG!

Mark,

Do you think the adipophilin in this case is following pattern 2 (both intracellular and extracellular after the distribution of palisaded or scattered histiocytes), according to Schulman & Leboit Am J Dermatopathol 2015; 37(3):203-9 (i.e. GA pattern), rather then the pattern 1 (extracellular, within zones of altered collagen) seen in NL.