Case Number : Case 1769 - 9 March - Dr Arti Bakshi Posted By: Guest

So what has Dr Arti Bakshi conjured up for you all today...

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A Lupoid conjuration...

There are many sclerodermoid features, but no silhouette squaring and much dermal mucin with hyalinized fatty necrosis make me favour Lupus Profundus

Superficial and deep infiltrate. At low magnification it seems mostly perivascular. Vacuolar change and necrotic keratinocytes at the DEJ. Some superficial neutrophils (I don't think I saw eos). Interstitial mucin. Lots of plasma cells. 

Lupus panniculitis

I would add ki67 to look for fat rimming, CD3, CD20, CD123

Always consider lymphoma in the differential 

Less likely but careful with syphilis unusual drug reaction 

Lupus profundus

Doubt syphillis but serologic studies if clinical concern, VDRL/FTA

Lupus profundus was my first thought, but the amount of plasma cells also warrant consideration of inflammatory morphoea. Can't comment much on cellular atypia but yes CTCL would be in the differential, if not for the numerous plasma cells

LE profundus with lovely lymphoid follicle formations.

Lupus profundus

I also think this is lupus profundus. The hyaline fat necrosis is a good clue as well as the prominent germinal centers. Considering the former, here in France they call it the «gui sign» or  mistletoe sing for the resemblance to a parasited tree.

Lupus panniculitis. What about an IHC to exclude lymphoma?

Yes, lupus profundus it is!

The combination of interface change, dermal mucin, hyalin fat necrosis, plasma cells and lymphoid aggregates (some clearly with reactive germinal centres) is typical of lupus profundus. Thanks for the instructive photograph, Raul!

Remember, one may not see all the features in any one case, which is why an SPTCL often comes in the d/d with lupus profundus. However, given the classical morphology in this case, one could debate if there really is a need for immunos. I'm sure the more experienced and braver dermatopathologists amongst us (such as Dr Carr!) would not do immunos. But I have to admit I have ordered a panel and although I dont expect to change my diagnosis, I await the stains....