Case Number : Case 2655 - 09 September 2020 Posted By: Dr. Hafeez Diwan

This has a granulomatous look to it.  The admixture of inflammatory cells and vascular dilation with endothelial swelling suggest granuloma faciale.  Against this is the paucity, in fact absence of eosinophils, a very dubious Grenz zone and also giant cells, which I don't think are a feature of granuloma faciale.  If the last view is PAS then I'm not sure what it is highlighting.

The apposition of giant cells and solar elastosis would also make me consider actinic granuloma.

If I might be allowed to dig myself out of a hole, the giant cells are Langhans' type, and the stain possibly ZN or Wade-Fite, in which case lupus vulgaris and leprosy are better candidates.

Granulomatous inflamation with fungal estructures inside of a multinucleated giant cell.

I´m thinking in Criptoccus but i´m not sure

Never seen a similar microorganism in a cutaneous site. This reminds me of Giardiasis...but this isn’t pas-positive, as far as I know ( it should be Giemsa or toluidine blu-positive ). I don’t know, but the this “animal” reminds me of something...

agree granulomatous inflammation with yeast like structures

? cryptococossis

GMS stain can help

I would keep differential of Histoplasma and Leishmaniasis. Tough to tell under H&E figure 3 and 4, it seems to have sheath and kinetoplast like structure. But if figure 4 is Giemsa/Toulidine blue and Figure 6 is PAS then it is PAS positive and does not takes up Giemsa, then it is Histoplasma. 

Thought of histoplasmosis too, but don’t see any vacuole. 

Maybe they are not microorganisms. Hamazaki Wesenberg bodies?

We called it Pityrosporum folliculits.

That's a tough one.  Were there any inflamed/occluded  follicles seen on other views?  Pityrosporum folliculitis of course is normally seen on the upper trunk in younger adults with numerous small follicular lesions.  It is not a diagnosis that one would normally think of for a solitary lesion on the face at this age.  Does that bring granuomatous rosacea into the equation?.