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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 1839 - 15 June - Dr Arti Bakshi 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: 71/F, widespread polymorphic rash, initially treated as scabies but no response.

Case Posted by Dr Arti Bakshi

Edited by Admin_Dermpath


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Admin_Dermpath

Posted

Get your brain cells working by tackling Dr Arti Bakshi's spot case.

Geoff Cross - DermpathPRO Projects

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dermpath1

Posted

You may wish to call it prurigo nodularis complicating scabies or nodular scabies causing lymphocytoma cutis.

Care should taken not to confuse reactive large CD30 positive cells with other cutaneous disorders with neoplastic CD30 positive cells..

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Raul Perret

Posted (edited)

I was considering CD30+ lymphoproliferative disease vs cutaneous compromise of anaplastic T cell lymphoma. Is there history of previous lymphoma? Some cells look like hodgkin's cells.

Edited by Raul Perret

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Anil Patki

Posted

Nodular scabies or persistent pruritic nodule after treatment of scabies. Does not respond to antiscabetics, requires topical or intralesional corticosteroids. Resembles lymphoma.

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Raul Perret

Posted (edited)

Yes, probably you guys are right I was not aware of this subtype of scabies. I have just read it on Weedon's book, thank you. CPC seems to be very important as even Weedon states in the last edition of his book that he misdiagnosed a case of Nodular scabies as Lymhpomatoid papulosis

Edited by Raul Perret

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vincenzo polizzi

Posted

The dermal lymphoid infiltrate looks secundary or less important compared to epidermal reaction ( I should see something deeper and more extensive in dermis for thinking to L.P. ). So agree with colleagues.  Persistent pruritic nodule after treatment of Scabies is a good diagnosis. 

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Raul Perret

Posted

17 hours ago, vincenzo polizzi said:

The dermal lymphoid infiltrate looks secundary or less important compared to epidermal reaction ( I should see something deeper and more extensive in dermis for thinking to L.P. ). So agree with colleagues.  Persistent pruritic nodule after treatment of Scabies is a good diagnosis. 

Thanks for the tip Vincenzo

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vincenzo polizzi

Posted

You are welcome Raul. Thank you for your many many suggestions. 

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Dr. Mona Abdel-Halim

Posted

Agree with you.

Nodular scabies, persistent insect bite reaction with CD30 positive cells. 

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Arti Bakshi

Posted

Interesting discussion! Clearly the case needs more clinical history so here goes....the diagnosis of scabies was the initial impression of a GP and patient was put on scabies treatment. However none of her lesions responded and she was then seen by the dermatologist, who did not think it was scabies at all! He took a detailed drug history and there was a possibility that the rash had started with the initiation of a new drug.  That was when this bx was done and the histology was reported as 'consistent with drug induced CD30 + lymphoproliferation'. The suspected drug was stopped but there was no response. In the meantime, patient developed a nodule (3 cm in size) on her elbow, which was biopsied and showed a diffuse infiltrate composed of  sheets of CD30+ pleomorphic cells (much denser that seen in these images from the bx of the rash). A clonality testing revealed the same clone in the background papular rash and the tumour nodule. Any thoughts on the diagnosis now?

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Pablo Gonzalvo

Posted

Lymphomatoid papulosis with pseudocarcinomatous hyperplasia?

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Raul Perret

Posted (edited)

Cutaneous (if clinically consistent) Anaplastic cd30+ large cell lymphoma evolving from lymphomatoid papulosis (would be the diagnosis of the bx you describe). This is then consistent with LyP 

Edited by Raul Perret

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Dr. Mona Abdel-Halim

Posted

So it is LyP

I have read in the cutaneous lymphoma book of Lorenzo Cerroni that large tumorous nodules can develop in the context of LyP. 

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vincenzo polizzi

Posted

Okay. GREAT CASE. But I was just wondering if this could be an odd case of cutaneous Hodgkin, for example a methotrexate induced HD (PAX5? CD15?)...

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Raul Perret

Posted

31 minutes ago, vincenzo polizzi said:

Okay. GREAT CASE. But I was just wondering if this could be an odd case of cutaneous Hodgkin, for example a methotrexate induced HD (PAX5? CD15?)...

The majority of cases of cutaneous Hodgkin lymphoma are seen in patients with advanced systemic disease. That is why I think it is important asking about the clinical history of the patient

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Arti Bakshi

Posted

I went for Lymphomatoid Papulosis for the background rash and regarded the tumour nodule as primary cutaneous ALCL. As we know, there is a known association between LyP and other cutaneous lymphomas including MF (I had posted a case of this before https://dermpathpro.com/spot-diagnosis-1/2016-spot-diagnoses/august-2016/case-1593-03-august-r1667/ ) and p-ALCL. The 2 lesions often share a common clone.

With regards to Mona's suggestion of the 2nd lesion also representing LyP (probably type C), this was certainly my initial thought when I saw the bx and was not aware of the size of the lesion. But it is unusual for LyP lesions to be more than 1 cm in size (except the angioinvasive variant). Ofcourse it is the course of the disease which is critical in the distinction as one expects self resolution and a waxing-waning course in LyP. However, its worth remembering that it can take weeks to months for lesions of LyP to resolve, hence the history of  'self resolving' lesions is not  always forthcoming from the clinicians, if patient is seen early enough. In this case, the lesions of LyP did eventually resolve after a couple of months, however lesions flared up again for which she is on phototherapy now (and well controlled). The tumour nodule showed no sign of regression and was treated with radiotherapy (as for primary cutaneous ALCL) and has now disappeared.

Thanks for all your comments and educative discussion!

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Arti Bakshi

Posted

@Vincenzo, the patient had a CT scan and did not have any significant lymphadenopathy. She also does not have have any history of Hodgkins.

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vincenzo polizzi

Posted

Okay Arti. Very nice case.  Thank you very much for your comments. 

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