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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 1477 -22 February 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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Case History: The patient is a 47 year old woman with a punch biopsy of a glistening, white, atrophic papule with telangiectasia taken from the left medial calf.

Case posted by Dr Mark Hurt


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Raul Perret

Posted

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

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Dr. Mona Abdel-Halim

Posted

Necrobiotic xanthogranuloma, atypical site though. Cholesterol clefts are characteristic together with the foamy cells and the Touton giant cells.

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vincenzo polizzi

Posted

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

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Nitin Khirwadkar

Posted

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

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Raul Perret

Posted

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

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Sasi Attili

Posted

Site typical for necrobiosis lipoidica. Histo more suggestive of NXG

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Arti Bakshi

Posted

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

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Dr. Mona Abdel-Halim

Posted

Sure the ddx should be NLD with the rare occurance of cholesterol clefts...

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vincenzo polizzi

Posted

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!

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Mark A. Hurt MD

Posted

Great Discussion!  Here is my diagnosis:

 

 

SKIN, LEFT MEDIAL CALF , SHAVE BIOPSY :

-- GRANULOMATOUS INFLAMMATION WITH XANTHOGRANULOMATOUS QUALITIES

AND CHOLESTEROL CLEFTS

COMMENT:  I suspect that this is probably an unusual expression of necrobiosis lipoidica.  The differential also includes necrobiotic xanthogranuloma.  As a rule, the presence of cholesterol clefts within a granuloma of NLD is uncommon.  Very few patients cases have been published having this finding, and the authors make a point that necrobiotic xanthogranuloma should be excluded on clinical and histopathological grounds if possible.  I discussed this set of findings with Dr. xxxxxx on 01/26/16 and will appreciate any additional followup once more information is known.

 

Reference

 

Gibson LE, Reizner GT, Winkelmann RK.  Necrobiosis lipoidica diabeticorum with cholesterol clefts in the differential diagnosis of necrobiotic xanthogranuloma.  J Cutan Pathol. 1988 Feb;15(1):18-21. PubMed PMID: 3351060.

 

Addendum:  The clinician indicated that the patient had a laboratory workup that showed elevated glucose, most compatible with necrobiosis lipoidica diabeticorum and not necrobiotic xanthogranuloma. 

 

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Dr. Richard Carr

Posted

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.

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Mark A. Hurt MD

Posted

Richard,

 

I thought it was more like pattern 2 (if I understand it correctly), but the context of the differential seemed more like NLD or NXG.  According to Schulman & LeBoit, it would seem to fit more with GA, but I don't think it is GA in this case.

 

Mark

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