Case Number : Case 1745 - 3 February - Dr Richard A Carr Posted By: Guest

This is definitely a 'Spot' case, have fun and enjoy your weekend

Geoff Cross - DermpathPRO Projects

This is a very interesting case. There are several granulomas types including suppurative, tuberculoid and histiocytic with necrosis and giant cells. My bet is for Sporotrichosis. There is some blue-gray material...Granulomatous foreing body reaction and Rheumatoid Nodule are my differential diagnosis.

Agree

Atypical mycobacteria vs. Sporotrichosis for stains and culture. 

Sporotrichosis is also my first impression. It is very difficult to see the fungi. The suppurative granulomas and the clinical description resembling a lymphangitic spread of the disease favor this diagnosis.

Given the clinical and H&E favor infectious, especially sporotichosis. Would do PAS and AFB and recommend cultures, even if negative.

Suppurative granulomatous inflammation. Agree with Sporotrichosis ( clinical picture fits). Would also consider an atypical mycobacterial infection/ ' Fish tank' granuloma.

The clinical description of lesional location reminds me of some wound patch, so agree with Sporotrichosis, but also with Fish Tank Granuloma.  I don't know the exactly answer....

Well done all on the correct differential.  This woman worked in a pet shop washing out fish tanks without protective equipment and this was clinically suspected to be Fish Tank granuloma. I reported it as suppurative granulomas in keeping with mycobacterium marinum.  I did not actually do Zn but I think I read in Weedon years ago that it is positive in up to 50% of cases.  I have not seen a case of sporotrichosis in the UK and will be very grateful to receive a case to photograph for Dermpathpro spot diagnosis.  I understand that it is one of the few conditions in which serial sections may be indicated to help find the organisms in the centre of the granulomas. It is one of my bug bears (pun intended) hearing people talk about serial sections when they mean step sections.  Serial sections produce a lot of slides! The blue grey material is elastophagocytosis - rather dramatic in this case but basically a secondary process - I'd hope it would lead to some confusion but you guys are too good!!