Case Number : Case 2284 - 15 March 2019 Posted By: Dr. Richard Carr

Pyogenic granuloma

Kaposi Sarcoma.

Ok. Agree of course!!! one time such a lesion, with this pyogenic-granuloma-like pattern, was called pseudobotriomychoma...

While commenting it as PG, was thinking of PG like kaposi, but just did not write. It should be included. 

I've been looking at PG's just a fraction longer since seeing this case from the routine pile!  It is sporadic pyogenic granuloma-like Kaposi's sarcoma (HIV and immunosuppression negative).

Enjoy your weekends and come on Ireland in Cardiff! England for the six nations Rugby championship.

References:

5 hours ago, Dr. Richard Carr said:

I've been looking at PG's just a fraction longer since seeing this case from the routine pile!  It is sporadic pyogenic granuloma-like Kaposi's sarcoma (HIV and immunosuppression negative).

Enjoy your weekends and come on Ireland in Cardiff! England for the six nations Rugby championship.

References:

1.McLain et al. Pyogenic Granuloma-Like Kaposi's Sarcoma. J Cutan Pathol. 2016 Jun;43(6):549-51. doi: 10.1111/cup.12679. Epub 2016 Apr 13.

2.Lee et al. Unusual case of pyogenic granuloma-like Kaposi's sarcoma on the sole. J Dermatol. 2015 Apr;42(4):425-6. doi: 10.1111/1346-8138.12811. Epub 2015 Feb 16.

3.Hamelin et al. Kaposi sarcoma mimicking pyogenic granuloma. Ann Dermatol Venereol. 2013 Oct;140(10):660-2. doi: 10.1016/j.annder.2013.04.101.Epub 2013 Jun 17.

4.Lee & Park.Kaposi sarcoma mimicking pyogenic granuloma below the toenail. Int J Dermatol. 2014 Mar;53(3):e202-4. doi: 10.1111/j.1365-4632.2012.05770.x.Epub 2013 Apr 28.

5. Scott PL1, Motaparthi K, Krishnan B, Hsu S. Pyogenic granuloma-like Kaposi sarcoma: a diagnostic pitfall. Dermatol Online J. 2012 Mar 15;18(3):4.

Thanks for sharing the case.  Do you find any specific histological clues as to when to suspect Kaposi's in a PG like tumor and ask for markers. 

In pyogenic granuloma the more solid cellular lobules are very tightly packed newly form small vessels with a rounded to oval pericytes surrounding central endothelium. The more cellular lobules in this case (observed in the low power) had spindle cells intervening between reactive vessels as highlighted in the bottom two H&E. That was the main clue. It is worrying how easily this could have been missed though so I suppose it's prudent with any PG just to take a good overview at low power and have a low threshold for a closer look. IHC will show the nice dual staining of endothelium (CD31) and pericytes/smooth muscle cells (SMA) in all the reactive vessels. Obviously all KS types light up with HHV8 and it's easy to do if you have any suspicions.

I'm in shock after the Rugby. Wales clinically beat Ireland (supposed to be the second best team in the world) and England nearly achieved the impossible of losing from 31:0 (looked like men against boys for 35 minutes) to draw 38:38 with a last ditch try under the posts (in extra-time). The highest score draw in international Rugby history! Wales worthy champions with the all important Grand Slam. I'm sick as a dog!

23 hours ago, Dr. Richard Carr said:

In pyogenic granuloma the more solid cellular lobules are very tightly packed newly form small vessels with a rounded to oval pericytes surrounding central endothelium. The more cellular lobules in this case (observed in the low power) had spindle cells intervening between reactive vessels as highlighted in the bottom two H&E. That was the main clue. It is worrying how easily this could have been missed though so I suppose it's prudent with any PG just to take a good overview at low power and have a low threshold for a closer look. IHC will show the nice dual staining of endothelium (CD31) and pericytes/smooth muscle cells (SMA) in all the reactive vessels. Obviously all KS types light up with HHV8 and it's easy to do if you have any suspicions.

I'm in shock after the Rugby. Wales clinically beat Ireland (supposed to be the second best team in the world) and England nearly achieved the impossible of losing from 31:0 (looked like men against boys for 35 minutes) to draw 38:38 with a last ditch try under the posts (in extra-time). The highest score draw in international Rugby history! Wales worthy champions with the all important Grand Slam. I'm sick as a dog!

Thank you for explaining when to suspect it. Since I read about it sometime ago, whenever I am signing out PG I am sceptical if I am missing out on a KS. 

what a beautiful case! thanks for sharing... Pyogenic granuloma-like Kaposi's sarcoma.