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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 2720 - 09 December 2020 Posted By: Richard Logan

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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M44, Rapidly growing lesion on right zygoma.


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?Severely inflamed SK, with underlying reactive PyG 

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Richard Logan

Posted

Only one brave soul offering an opinion! 

Here's a clue: Carmena Burana.

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Krishnakumar subramanian

Posted

some procedure done over Seb keratosis with pyogenic granuloma response

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21 hours ago, Richard Logan said:

Only one brave soul offering an opinion! 

Here's a clue: Carmena Burana.

OK, it´s easier now! Ecthyma contagiosum (Orf).

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Richard Logan

Posted

Well done Igor - obviously the clue was too easy.  This was a florid case of giant orf.

The patient presented to me with the lesion as shown in the photograph.  The clinical diagnosis was straightforward as the patient was a small-holding farmer who had been bottle-feeding newborn lambs.  Orf is well-recognised in rural sheep-farming areas, and is usually left alone to resolve spontaneously over about a three week period.  For obvious reasons the most common site of involvement is the hand, but occasionally, as in this case, lesions can present at other sites, presumably either because of direct inoculation, or inadvertent transfer of the virus from the hand.  This case was also strikingly unusual because of the subsequent clinical course.

We initially managed the patient "expectantly", in other words doing nothing to await the normal resolution.  Unfortunately the primary lesion expanded alarmingly to about 5cm in diameter, and encroached on the patient's eyelid.  This prompted urgent surgical intervention in the form of curettage from which this histology was obtained.  Unfortunately surgery was followed by an alarming eruption of numerous satellite lesions.  These were left to resolve spontaneously.

if you want to see how the case developed we wrote it up: 

Key SJ, et al. J Craniofac Surg 2007 18(5): 1076 - 1078.

 

I think the histology of this case differs from a pyogenic granuloma in that the vascular congestion is more marked with larger vessels.  The epidermis shows a rather more lobulated structure than might be expected in a pyogenic granuloma.  In addition, there is a clue to the viral aetiology with the epidermal cytopathic changes of vacuolation and clumping of keratohyaline.

 

In my perambulations through the cases in the SpotDiagnosis section of the website, I came across only one other example of orf posted by Richard Carr on 29th November 2019, case 2455.  That was a more subtle example than this florid case.

Giant Orf.jpg

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Nice case of Orf. Thanks for sharing. 

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