Case Number : Case 1824 - 25 May - Dr Arti Bakshi Posted By: Guest

Dr Arti Bakshi tells me that you have a treat of a Daily Spot Diagnosis Case today, enjoy.

Geoff Cross - DermpathPRO Projects

Superficial vegetative (granulomatous) pyoderma gangrenosum.

I remember well a case of ?rheumatoid neutrophilic dermatosis in which I found acid fast bacilli!  Needs usual bug stains and cultures but certainly a granulomatous variant of pyoderma gangrenosum is a good suggestion. Rather impressive giant cells I thought.

Its a suppurative granuloma. Deep fungal infection to be ruled out in an immunocompromised patient.

This looks like a suppurative granulomatous dermatitis in an immunocompromised host, infective causes is a priority to exclude through appropriate triple tissue cultures (mycobacterial, fungal and bacterial). Non-Tuberculous Mycobacterium (NTM) infections especially Mycobacterium Chelonae is frequently isolated in these patients (in the U.K. in my experience) particularly those on oral Prednisolone as part of their treatment regime. Once infective aetiology excluded, neutrophilic dermatosis is fairly reasonable to consider next including PG. 

Was this lady was on Prednisolone as part of therapy regime out of intertest? certainly it can be seen with any immunosuppressives. 

Thanks

Suppurative diffuse dermatitis with multinucleate foreign body giant cells. Agree with pyoderma gangrenosum, associated with rheumatoid arthritis.

It should be rule out infectious suppurative granulomatosa infection. Muy be superficial granulomatous pyoderma .

Agree with special stains to search for microorganisms as well as culture. If both negative, it could be superficial vegetative pyoderma gangrenosum

Yes, this is a superficial granulomatous pyoderma gangrenosusm. So well done to all!

An infective eitiology, ofcourse, needs to be excluded in all such cases.The patient had multiple biopsies, all reported as granulomatous r/o infection. Special stains were repeatedly negative,tissue was sent for culture and PCR and these too were negative.The patient was on Adalimumab for RA.  Once a diagnosis of granulomatous PG was made in our CPC meeting, some more immunosuppressive agents were added and this led to rapid healing of the lesions. 

Although called superficial, lesions of superficial granulomatous PG can be fairly deep seated (as in this case). The zonal pattern of inflammation is typical and mutinucleate giants (plus plasma cells) are also characteristic. This variant typically follows a more indolent course than classic PG.

Thanks for all your comments!

Nice to see some new people putting in comments! Welcome to all!

Thanks for the feedback on this interesting case with a good learning point and the welcome. Hope occasional comments from Clinicians is accepted in this platform among Dermpath colleagues and we learn from each other.

Ofcourse Saman! This website is for all with an interest in learning dermpath. There are many dermatologists who have contributed over the years and we have  learnt so much  from their  clinical perspective....it is this close link between dermatology and pathology which makes dermpath so unique (and undoubtedly the best subspeciality of histopathology!)