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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 1730 - 13 January - Dr Richard A Carr 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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Clinical History: F60. Wrist. 2-3 years of erythematous papules + plaques, wrists, ankle/dorsum of hands. ?Granuloma annulare.

Case Posted by Dr Richard A Carr

Edited by Admin_Dermpath


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Admin_Dermpath

Posted

Here is your Friday the 13th Special from Dr Richard A Carr with IHC images to be added at 6pm-ish GMT, I hope this is not too scary a case  :-)

 

Geoff Cross - DermpathPRO Projects

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vincenzo polizzi

Posted

Clinical history and histological features ( lamellar fibrosis of papillary dermis, Pautrier abscess, linear lymphocytic infiltration of basal layer, atypical epidermal lymphocytes larger than intradermal ones ) make me favor Mycosis Fungoides. 

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Robledo F. Rocha

Posted

Sites of the lesions are not the expected ones for mycosis fungoides, so maybe it is a spongiotic dermatitis with a few epidermotropic lymphocytes lined up along basal layer and a Langerhans microabscess in the fashion of a Pautrier simulant.

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Nitin Khirwadkar

Posted

Agree with Robledo. Eczema, almost EAC like in image 1.

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vincenzo polizzi

Posted

Erythema annulare centrifugum-like mycosis fungoides.

Ceyhan AM, et al. Australas J Dermatol. 2011.

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Raul Perret

Posted

Also thought of spongiotic dermatitis, the dermal infiltrate is quite prominent though.

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Dr. Mona Abdel-Halim

Posted

I would love to c a CD3 and CD1a first to verify what we r seeing in the last image. A true Pautrier's microabscess or a Pautrier simulant. 

But provisionally, I am favoring a spongiotic reaction. To me, the epidermis is too spongiotic for MF and overall looks inflammatory.

The dermal infiltrate is quite dense though. Some coat sleeve impression. 

Some basilar lymphocytes?? Seems annular in configuration (since the ddx is GA). So may be it is EAC with pautrier's simulant. Waiting for the immunos!!!

 

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I think this is a spongiotic dermatitis simulating MF with those Pautrier-like microabscesses. I would like to see immunostains for CD3 and CD1a as well, but at H&E it looks like langerhans cells. I agree with Mona´s observation that the clinical impression of GA may be a clue for EAC or contact dermatitis.

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Arash Daryakar

Posted

I like to rule out MF by IHC in this case.Although,spongiosis is too prominent to be MF.

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Arash Daryakar

Posted

lt seems intraepidermal lymphocytes have loss of CD7 and CD8 neg . am i right?

so its more likely to be MF

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vincenzo polizzi

Posted

Let me explain in details why favor MF over the other mimics:

1) the epidermal abscess is a true pautrier for me, because nucleus are hyperchromatic, lymphocytic, in opposite to vescicular and reniform of LC.  And the epidermal lymphocytes are twice large than dermal ones  

2) it's too important for me the "lamellar fibrosis " of papillary dermis. It isn't diagnostic off course but it's an useful clue to MF. 

3) 2/3 years of clinical history fit in with chronic disease than acute/subacute one ( like the lamellar fibrosis fit in better with a long time junctional epidermal dermal process  ). 

4) IHC isn't conclusive alone, but it fit very well in with the above, doesn't it?

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Dr. Richard Carr

Posted

Well done Vincenzo.  I agree with your diagnosis favouring mycosis fungoides (CD3+, CD4weak, CD7 loss, CD8-, clonal for TRG and TRB) currently being observed (pT1b skin limited disease). We can see spongiosis in mycosis fungoides although often the shear number of epidermotropic, hyperchromatic, lymphocytes remains disproportionate to the degree of spongiosis.  I agree with considering a Langerhan's cell pseudo-pautrier microabscess although Langerhan's cells typically have somewhat paler nuclei with more open chromatin and gentle folded (reniform) nuclei with more abundant pale eosinophilic cytoplasm (surprisingly could not find an example of such on dermpathpro - keep your eyes out though). I found the rather monotonous peri-vascular B-cells of some confusion, never having seen this pattern before so asked for B-cell clonality and this showed a weak polyclonal pattern). I'm guessing it was the latter pattern that led to some confusion with erythema annulare.

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Raul Perret

Posted

Well done Vincenzo, another thing learned today!

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Robledo F. Rocha

Posted

After immunohistochemical images, this is mycosis fungoides with odd clinical presentation and with odd microscopic features. Diseases definitively do not read Dermatopathology Textbooks!

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