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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 1773 - 15 March - Dr Hafeez Diwan 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: 61 year-old female with multiple lesions on legs. This biopsy is from the left shin.

Case Posted by Dr Hafeez Diwan


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Admin_Dermpath

Posted

Lots of images to give you all the information you need to solve today's Spot Diagnosis Case posted by Dr Hafeez Diwan

 

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Raul Perret

Posted

Looks like a large vessel with prominent intramural inflammation and thrombosis. The elastic fiber pattern makes me think more of a vein but it is hard to see the internal muscle layer. In addition eosinophils seem prominent. My differential is PAN/Churg-Strauss vs thrombophlebitis migratory/etc. In these kind of cases CPC is extremely important.

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vincenzo polizzi

Posted

I think this is a vein, because there are collagen bands between the muscle layers, so my first thought is Nodular Vasculitis ( the inflammatory pattern is suppurative and granulomatous). I would like to se more pictures of subcutaneous tissue...in fig 5 you can try to appreciate a septal-lobular panniculitis, but it's arduous! 

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The multiple fragmented elastic fibers inside the muscle wall points to a vein. Ths subcutaneous tissue on picture 5 seems little affected. When putting clinican information together, my first impression is superficial thrombophlebitis.

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vincenzo polizzi

Posted

I'm starting thinking of Wegener Granulomatosis as differential...

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Nitin Khirwadkar

Posted

What about a necrotising granulomatous vasculitis associated with erythema induratum?

Wegener's generally tends to spare the legs, but exceptions can be there.

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Robledo F. Rocha

Posted

Elastic fibers are scant and fragmented throughout the tunica media of the vessel, so it’s a vein. The smooth muscle pattern might be an additional indication, but it is difficult to access due to the obscuring inflammation. Assuming this vessel as a vein, and it is likely to be, a thrombosed subcutaneous vein with mixed infiltrate in its wall and what seems to be only a little inflammatory involvement restricted to the perivascular area makes me favor superficial thrombophlebitis.

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Dr. Hafeez Diwan

Posted

My differential was Churg-Strauss  and PAN.  I also thought about Wegener's.

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Mariantonieta Tirado

Posted

Tough. All comments are valid differentials. The 5th picture looks arterial to me plus eos, neutrophils inclined to Churg-Strauss, Wegener  or PAN. Multiple lesions and bilateral apparently.

I would expect a thrombophlebitis to be unilateral and following the vein. A certain pattern of lesions is not specified.

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Sasi Attili

Posted

All are valid differentials. Needs CPC- I find these cases tough. The last slide shows eosinophils. Drugs excluded?

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Alice Roberts

Posted

Arteritis. Differential includes PAN, drug related,possibly Wegeners or Churg Strauss. Eosinophils admixed with neutrophils but don't seem abundant.

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