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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 2741 - 7 January 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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54F punch biopsy chest – known Behcet’s ?neutrophilic folliculitis


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Richard Logan

Posted

I see a focal area of modest, psoriasiform epidermal hyperplasia with overlying parakeratosis.  The affected epidermis shows mild dysplasia and an increase in mitotic activity, which together make me think this is a solar keratosis.  I would do a PAS stain, expecting it to be negative.

In addition there is a modest perivascular lymphocytic infiltrate (some might call it lymphocytic "vasculitis") which may be a reflection of the underlying Behcet's disease.  The dermal collagen looks rather fragmented which might be due to systemic steroid treatment.

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Alex-Ventura-Leon

Posted

Maybe I´m out of track but I´m thinking in Grover disease.

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Krishnakumar subramanian

Posted

Focal Psoriasiform epidermal changes with dermal perivascular lymphocytes

Get a PAS done to rule out fungus

I am not able to think beyond this, there is no granuloma or tumor in the dermis

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Meenakshi Batrani

Posted

On 08/01/2021 at 08:48, Alex-Ventura-Leon said:

Maybe I´m out of track but I´m thinking in Grover disease.

Yes, I am also suspicious of Grover's ds.

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Leila Ahmed

Posted

3 more levels and a pasx3 strip please

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vincenzo

Posted

Not sure, but favor Grover’s disease. 

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Richard Logan

Posted

For a diagnosis of Grover's wouldn't you expect to see some acantholysis?

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vincenzo

Posted

Not sure, Richard, but I seem to see a subtle acantholysis in fig 4...

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Alex-Ventura-Leon

Posted

Grover disease can have patterns with minimal acantholysis. Here a relevant paper: https://pubmed.ncbi.nlm.nih.gov/20526170/

I had the same impression as Vincenzo and interpreted figure 4 as subtle acantholysis.

However, i´m speculating and i´m looking forward for the final answer

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Saleem Taibjee

Posted

Yes this is Grover’s disease. I did request levels, which did not significantly differ on this biopsy i.e. the rather subtle acantholysis did not become more prominent. However, in fact the patient had 2 biopsies. The histology from the second biopsy is shown below. As you can see it clearly showed acantholytic dyskeratosis.

The important lesson here is that elongation of rete ridges (solar lentigo-like) is a useful clue to ‘early’ Grover’s, and is highlighted in at least 2 publications – see below, as well as receiving a mention in Weedon’s textbook.

BW

Saleem

20WSZA37009 -- 20C32939 -- Swift -- B1 -- Steps 1-3 -- Taibjee_5.0x.jpg

20WSZA37009 -- 20C32939 -- Swift -- B1 -- Steps 1-3 -- Taibjee_20.0x.jpg

20WSZA37009 -- 20C32939 -- Swift -- B1 -- Steps 1-3 -- Taibjee_40.0x.jpg

Grover's publications.jpg

 

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Richard Logan

Posted

Thank you everyone.  I thought acantholysis was a sine qua non for Grover's diseaseWith the eye of faith looking through a retrospectoscope I can see the very subtle changes of acantholysis in image 4.  Certainly acantholysis is much more obvious in the second biopsy Saleem.

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