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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 2566 - 07 May 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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51M, fibrous fatty lesion/nodule left forearm. Multiple lesions over forearms, ex-tensor aspects.


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Saleem Taibjee

Posted

OK, Vincenzo. As requested! Alcian blue x 2 areas

01541_20.0xAB.2 labelled.jpg

01541_20.0xAB.3 labelled.jpg

 

 

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Krishnakumar subramanian

Posted

sub cutaneous Granuloma annulare

 

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John Zhang

Posted

If we can rule out mycobacterial infections, this can be either rheumatoid nodule (if history of rheumatoid arthritis) or deep GA. Anatomic site is good for rheumatoid nodule.

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Meenakshi Batrani

Posted

Juxta-articular GA (Pseudorehumatoid nodule). But clinical correlation and other ancillary tests to exclude Rheumatoid nodule, and also Fite to exclude atypical mycobacterial infection. 

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Victor Delgado

Posted

Agree with all of you guys. Deep GA vs. Rehumatoid Nodule. Thanks for sharing. Beautiful!!!

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Saleem Taibjee

Posted

Thanks for the interesting comments. 

Yes, the main differential diagnosis in this case is deep granuloma annulare vs rheumatoid nodule. In fact, this case was understandably originally signed out as Rh nodule by the original pathologist.

The table from McKee is shown below showing the main discriminating features between palisading granulomatous inflammation.

Differential diagnosis.jpg

As you can see, detection of mucin (either on H&E or Alcian blue) can be very helpful in deep GA. This case also had sarcoidal features, which is a further variation of GA histologically. I also show the Martius Scarlet Blue below, which seems negative i.e. no evidence of fibrin, as would be perhaps expected if Rh nodule.

01541_10.0x MSB labelled.jpg

It later transpired, once the patient was seen in Dermatology, that the patient had a polymorphous cutaneous picture (see example photo below of annular plaques in this patient), much more in keeping with GA. Interestingly other biopsies on this patient showed more 'conventional' GA or 'interstitial' GA patterns. A good example of the need for clinical correlation and multiple biopsies.

GA clinical.jpg

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Dr. Mona Abdel-Halim

Posted

Lovely! CPC is the key in dermatopathology!

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Krishnakumar subramanian

Posted

Thanks a lot for sharing this case Dr

Retrospective must we have also thought of epithelioid sarcoma in DD. i sew there is no atypia, inputs welcome

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