Case Number : Case 1889 - 24 August - Dr Iskander Chaudhry (Invited) Posted By: Guest

I am a bit puzzled by this case, there is mainly a lymphocytic infiltrate with excessive tropism towards blood vessels and hair follicle, destroying the later. I thought of a vasculopathic reaction process with folliculitis and prominent lymphocytes, for example Behcet's disease or lupus? but the clinical image does not perfectly fit with the typical skin manifestations of these diseases, is there any more clinical information? 

I think I would do a PAS stain too in case there are is a combination of pathologies

Dear Raul

No more history than provided - lesions come and go! 

Iskander

Follicular Lymphomatoid Papulosis? 

Yeah I thought of that dx at the beginning but does it fit the clinical image?

Clinical features, granulomatous infiltrate in lower dermis and subcutis with panniculitis, all point to erythema induratum (Bazin's disease)

Yes this is lymphomatoid papulosis with follicular compromise I do not know what was I thinking..

Dear All 

CD30 shows only scattered cells! Try again! 

Iskander

2 hours ago, Raul Perret said:

Yes this is lymphomatoid papulosis with follicular compromise I do not know what was I thinking..

LyP localised to just the legs? Is that described?

Not sure what to call this. There are granulomatous changes around the follicular unit. Lichen scrofulosorum? Clinical doesn't quite fit though!

Considering the suppurative folliculitis with surrounding Sweet’s-like vascular reaction, sterile neutrophilic folliculitis with perifollicular vasculopathy is a possibility. Clinical history fits as well, especially if there is an associated systemic disease as Raul said above.

Recurrent insect bite reaction? But it should show eosinophils and no panniculitis!

44 minutes ago, Robledo F. Rocha said:

Considering the suppurative folliculitis with surrounding Sweet’s-like vascular reaction, sterile neutrophilic folliculitis with perifollicular vasculopathy is a possibility. Clinical history fits as well, especially if there is an associated systemic disease as Raul said above.

yeah I read about that entity Robledo, but it is supposed to be primarily neutrophils in the dermis and this looks mainly as a lymphocytic process? do you guys agree? I am clueless, I suppose immunofluorescence was not performed in this case?

It is very interesting to see clinical photos beside the photomicrographs! Admin team have to be congratulated for this new feature.

Clinically red-brown "granulomatous" plaques, some are folliculocentric with subtle superficial scale and light brown post inflammatory hyperpigmentation in older lesions. It is bilateral and intermittent, would be nice to clarify is she shaves her legs or uses other mechanical methods for hair removal?

The main feature is a granulomatous infiltrate with large numbers of lymphocytes centred around what appear to be a hair shaft in the middle of dermis. It appears like a reactive process to a foreign body (hair shaft granulomas) but no obvious giant cells. I thought about possibility of Majocchi granulomas though bilaterality will be slightly unusual (but still possible). Other DDx cutaneous mycotic infection with "pseudolymphoatous" infiltrate but the histology is not typical of this. Lastly one should bear in mind externally introduced material for longstanding lesions in easily accessible sites if clinical context is appropriate and other causes excluded.

Dear All 

Dr Chaudhry has added the DPAS stains. We can add clinical images if provided by the contributors with appropriate consent! Final diagnosis  ....

DermpathPRO Admin. 

Majocchi's granuloma

Agree with Majocchi’s granuloma, but, wow!, more than one decade, how long time!

This is so interesting, the last picture was suspicious showing the hair shaft with some «tubular» structures thats why I added the comment of the PAS stain. I just thought it was highly unlikely due to the clinical. So nice to have cases like this one and keep learning everyday, thank you colleagues and the editorial team

On 8/25/2017 at 11:15, Raul Perret said:

This is so interesting, the last picture was suspicious showing the hair shaft with some «tubular» structures thats why I added the comment of the PAS stain. I just thought it was highly unlikely due to the clinical. So nice to have cases like this one and keep learning everyday, thank you colleagues and the editorial team

Absolutely. I wondered about fungus for a fleeting second, but dismissed it based on the clinical!