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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 2487 - 16 January 2020 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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79F with multiple erythematous papules


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There is a vague dermal elastosis.Elastic fibers  disorders (mid-dermal elastolysis,anetoderma,  ...etc) need to be excluded.

But this looks cutaneous mastocytosis.

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Some vascular spaces in fig 2 and 3 look like a promontory sign...Favor Kaposi's sarcoma, patch stage.

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Krishnakumar subramanian

Posted

sir, patch stage of KS is difficult histology diagnosis. I need IHC 

also the clinical description tells papules, 

However, there are perivascular lymphocytes and plasma cells and slit like vascular spaces. some actinic damage is seen in the dermis.

 

 

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There's perivascular and interstitial mononuclear cell infiltrate with some mucin. There is also an incidental pseudolipomatosis cutis.। think that this is papular type of granuloma annulare presenting as multiple papules and histologically as interstitial type. 

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Dr. Richard Carr

Posted

Tricky. Blind H&E both mastocytosis & KS went through my head too. Not sure it's either to be honest. Are there colloid bodies? May be do some levels to find the "papule". 

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Meenakshi Batrani

Posted

There is an occasional eosinophils and probably mast cells. Need stains for mast cells. Could be cutaneous mastocytosis- TMEP. Otherwise some dermal hypersensitivity reaction although eosinophils are occasional.

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Saleem Taibjee

Posted

Well done guys! Yes, this was a pretty subtle (not quite 'invisible') example of mastocytosis. Fortunately for me, the clinician had suggested the diagnosis. The case was passed to me by another pathologist who wasn't too sure. However, once aware of the clinical suspicion I was pretty confident. I did request a CD117 (see below) for confirmation, which shows there are many more mast cells than one first appreciates. The difficulty of the case is that many of the mast cells are rather spindled which I think is the pitfall, and when it can be missed. As Meenakshi mentions, occasional eosinophils can be a clue.

I tend not to try to subtype mastocytosis on the histology, because this aspect really depends on clinical correlation. Furthermore, the classification of mastocytosis seems to be constantly changing! See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5356454/?report=reader

I don't have clinical photos on the current case since it is a backlog case from another hospital. However, I include a couple of clinical photos on one of my own patients with confirmed mastocytosis. I suspect the current case might look somewhat similar.

59174_20.0x CD117 labelled.jpg

001.jpg

003.jpg

 

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Nabil Mansouri2

Posted

Guys mastocytosis went through my mind too. Thanks God hhh . Thank you so much Saleem Taibjee for such a lovely case indeed

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