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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 2801- 1 April 2021 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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52M – punch biopsy left elbow: ulceration on legs and scaly nodules on elbows


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Richard Logan

Posted

There is an interstitial pattern of granulomatous dermal inflammation which includes prominent neutrophils.  I think this would fit into the description of (not very) palisaded neutrophilc granulomatous dermatitis.  With the history of leg ulceration I would consider rheumatoid disease as a recognised association.

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Eman El-Nabarawy

Posted

Characteristic site of palisaded neutrophilic and granulomatous dermatitis.. 

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Saleem Taibjee

Posted

Not all of the images have been posted. I'll ask if this can be done.

 

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Saleem Taibjee

Posted

I should have also said ... You're in the right ballpark, but I think can be more specific.

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vincenzo

Posted

Palisaded neutrophilic interstitial granulomatosis...with some resembling Wegener granulomatosis, but I don’t see any vasculitis. 

 

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Richard Logan

Posted

You're a hard taskmaster Saleem!

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Saleem Taibjee

Posted

Richard, this is how you like it! Vincenzo has shown the way... Unfortunately there is an issue with DermpathPro at the moment, ordinarily I would be able to upload images directly, including the nice clinical images on this case, but I am unable to at the moment.

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HENRY

Posted

Always enjoy the cases posted on dermpathpro here, and Thank you all for the contribution of nice cases for education purposes. Dr Saleem always have interesting cases and I love your high quality images and detailed explanation. For this case, I would agree the thought process if Dr Logan and Dr Vincenzo's ideas of PNGD. however, for this kind of lesions, when I saw a little cytologic atypia with mitosis (like seen in this case), I would throw some CK and EMA there just not want to miss epithelioid sarcoma.  

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Saleem Taibjee

Posted

Hi. It's a shame that the additional images including clinical photos have not appeared.

The patient has scabby nodules on his elbows, and large irregular ulcers on his legs with eschar.

He is known to have granulomatosis with polyangiitis (Wegeners), with nasal sinus disease and lung manifestations. The cutaneous features are more recent.

The histology is very characteristic, with 'basophilic' 'geographic' palisading granulomas very suggestive of this specific disease. This contrasts with more eosinophilic but similar geographical areas we might see in allergic granulomatosis with vasculitis (Churg-Strauss). The hypothesis is that the curious pattern of collagen necrosis arises due to vasculitis and resultant tissue ischaemia. It probably does represent a subset of palisaded neutrophilic granulomatous dermatitis, but I think the basophilic collagen necrosis is a more specific clue to this particular underlying diagnosis.

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Richard Logan

Posted

Very instructive as usual. Thank you Saleem.

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Saleem Taibjee

Posted

The clinical images and other histology images have now been posted for this case above

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Krishnakumar subramanian

Posted

Thanks Dr

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vincenzo

Posted

Thanks , Saleem. 

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