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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 2253 - 31 January 2019 Posted By: Raul Perret

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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Male 44 years old, painful nodule in the finger for 2 months


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glauco

Posted (edited)

Sporotrichosis

Edited by glauco

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Dermal suppurative and epithelioid granuloma with a vague zoning pattern: inner suppurative zone with neutrophils, mid zone of epithelioid granuloma with giant cells and outer zone showing lymphoplasmcytic inflammatory cell infiltrates. this pattern does bring cutaneous Sporotrichosis into consideration. I did not see clearly fungal yeasts or the so called Splendore-Hoeppli phenomena. but maybe missed it, Raul, do you have GMS image to show us? so far, also favor sporotrichosis.

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What about a Mycobacterium Marinum-related granuloma(fishtank or swimming-pool or aquarium)?

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Krishnakumar subramanian

Posted

infective granuloma

special stains like GMS/AFB needed

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Suppurative granulomatous inflammation suggests a deep fungal infection or atypical mycobacterial infection. Etiologic diagnosis is by special stains and culture of the piece of tissue. 

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Alex-Ventura-Leon

Posted

Suppurative granulomatous inflammation whitout a epidermal changes (quite rare in my experience for sporotrichosis) make me think in Atypical Mycobacterium Infeccion. Marinum is a great suggestion.

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Raul Perret

Posted

Great comments. This was a suppurative and granulomatous dermatitis due to Mycobacterium Marinum. The patient was a duck breeder who mentienod frequently hurting his hands while handling the animals.

I think the most important lesson of this case is that this histological pattern is virtually always associated with an infectious etiology (either fungus or BAAR). However, do remember that the sensitivity of BAAR staining for detecting microorganisms is quite low in histological sections (I did 6 Ziehl-Neelsen stainings in this case and did not find a single bug!). In spite of this aspect, the probable infectious etiology should be mentioned in the report.

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