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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 2444 - 14 November 2019 Posted By: Saleem Taibjee

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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67 year old man with persistent plaques right flank and buttocks. Lack of response to psoriasis creams.


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First thing I would do is a PAS stain and look for hypha (tinea incognito).

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Krishnakumar subramanian

Posted

neutrophilic spongiosis

PAS stain to rule out dermatophytosis

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Many neutrophils and capillaries on tip of dermal papilla make me think of a psoriasis ( maybe drug resistant). 

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If dermatophytosis is ruled out by PAS stain, pityriasis rubra pilaris should be considered in the differential diagnosis as there's irregular acanthosis and parakeratosis alternating with orthokeratosis

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Victor Delgado

Posted

Psoriasis and Dermatophytosis are great differentials, I´ll suggest nutritional deficiency aswell, there is a little bit of vacuolar degeneration and a few necrotic keratinocytes so we should think on drugs Rx aswell. Clinical correlation.

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Last figure:

looks like a little vacuolar interface as Victor mentioned. There appears an increase of interstitial mucin. What are the  perivascular cells? Some are lymphocytes but many are not. Mast cells?

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Krishnakumar subramanian

Posted

sir once we something like mucin in dermis I would like to rule out dermatomyositis

however there would be other clinical parameters and lab support

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Saleem Taibjee

Posted

You guys are good! Yes this was tinea incognito. The PAS stain and striking clinical appearance is shown below, before and after treatment with oral antifungals.11252_40.0x b PAS.jpg11252_37.0x PAS.jpgTinea incognito - case Mr CC.jpegTinea incognito(1).JPG

 

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Krishnakumar subramanian

Posted

sir wonderful

common things are common

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