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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 2900 - 18 August 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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29F, incisional biopsy mid-back: Progressive pigmentation on mid-back


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Krishnakumar subramanian

Posted

necrotic keratinocytes and pigment incontinence in dermis

could it be a drug rash

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Richard Logan

Posted

The low-power views suggest confluent and reticulated papillomatosis, with blunt-topped papillomatosis and a degree of epidermal invagination by orthokeratotic keratin.  However, at higher power there is pigmentary incontinence and a lot of amorphous bodies in the papillary dermis.  Therefore I think I would want to do amyloid stains, with amyloid being my preferred diagnosis.

I noticed the necrotic keratinocyte but there was only one that i could see, so the features above seem more pertinent.

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Krishnakumar subramanian

Posted

agree sir, could be lichen amyloid

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Amorphous hyaline material in the papillary dermis, favor amyloid.

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Fav amyloid, mid back usually macular amyloid 

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Saleem Taibjee

Posted

Hi. Yes well done, this is a recent case of macular (cutaneous) amyloid. As Volha mentions, this is the subtype of cutaneous amyloid typically seen on the back, and shows a characteristic rippled macular  pigmentation pattern clinically. It is another example of 'invisible' dermatosis (or easily missed pathology).

It is also worth noting that keratin stains are usually more helpful than traditional amyloid stains such as Congo red in such cases. I include the relevant stains below. Interestingly, the choice of keratin stain does seem to matter, some cases seem to stain better for one pankeratin (e.g. MNF116, AE1/AE3, 34BE12) than another. But I am yet to make a firm conclusion as to which is the best, and might suggest requesting a couple of IHC stains in such cases. For example, AE1/AE3 was rather weak in this case compared to MNF116 and 34BE12.

BW
Saleem

34579_20.0x AE1AE3 labelled.jpg

34579_20.0x 34BE12 labelled.jpg

34579_20.0x MNF116b labelled.jpg

34579_20.0x Congo red labelled.jpg

 

34579_20.0x AE1AE3 labelled.jpg

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