Case Number : Case 1750 - 10 February - Dr Richard A Carr Posted By: Guest

Round off your week with another great case from Dr Richard A Carr

Geoff Cross - DermpathPRO Projects

I think of DLE at first look. although due to presence of eosinophils one can think of drug induced LE.

another thing is presence of nuclear debries among inflammatory cells.leukocytoclasia??

Agree that there are findings which makes me think about Lupus: interface change, thickening of the basement membrane in figure 8, many lymphoid nodules extending to subcutaneous tissue, perifollicular inflamation and telangiectasias. The neutrophils may be in a context of a LE with neutrophils.

could this be lupus profundus?

Well me I had the impression of a really inflammatory rosacea / demodicosis. There is telangiectasia, demodex and I had the impression that the inflammation is mainly centered on hair follicles. I would definately do a PAS staining too here. 

All good thoughts above. Just to add to the d/d what about an odd Granuloma faciale? The images with mixed infiltrate (neutrophils and eosinophils) with leucocytoclasia would very well for GF But there is no Grenz zone and difficult to explain the dense perivascular and periadnexal lymphocytic infiltrate. Difficult!

I think there are two manifestations of the same disease: Lupus Erythematosus. 

A chronic cutaneous lupus and a lupus profumdus. I don't know exactly what it's happening in this patient but may be some drug could have blown up a chronic autoimmune status in his face. 

"Neutrophils in the setting of systemic lupus erythematosus (SLE) are commonly associated with bullous disease. Rare cases of nonbullous neutrophilic lesions have been reported in patients with SLE".

Looks like DLE as the basic process. Can't go away from the markedly thickened basement membrane. Eosinophils and neutrophils, slightly odd. So, GF with DLE?

DLE/LE profundus is my prefered hypothesis... neutrophils can occur in the context of lupus. Esinophils r sparse, odd in LE ?? But can't think of something else. 

Lupus profundus?

Glad you guy's also found this case challenging. Agree the main pathology is the discoid lupus (DLE). I was confused by the eosinophils and neutrophilic leucocytosis (these were mainly quite deep and in one area of this generous incision biopsy. My thoughts were similar to the responses i.e. it could all be a manifestation of lupus or perhaps dual pathology - granuloma faciale-like. Sometimes there is a call to speculate in the reports which is what I did on this case mentioning both possibilities.  It is recent but i'll try to get some follow-up and post later.