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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 2917 - 10 September 2021 Posted By: Dr. Richard Carr

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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F70. Proximal lateral leg. Pale brown telangiectatic. Fair skin. History of psoriasis. DDx: Burned out lichenoid keratosis?


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Meenakshi Batrani

Posted

To me appears like a tiered pattern of necrobiosis and fibrosis, with few giant cells and aggregates of plasma cells. Pigment at the top likely to be hemosiderin. I am thinking of necrobiosis lipodica. 

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51 minutes ago, Meenakshi Batrani said:

To me appears like a tiered pattern of necrobiosis and fibrosis, with few giant cells and aggregates of plasma cells. Pigment at the top likely to be hemosiderin. I am thinking of necrobiosis lipodica. 

Yes. Difficult case for me, because the stratified layers of necrobiosis don’t appear striking, but Necrobiosis Lipoidica was my first thought too. 

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Dr. Richard Carr

Posted

These are Kappa & Lamda as Vincenzo as worked out and the patient does have a monoclonal gammopathy. Are there any other diagnostic considerations in this setting other than NL?

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Dr. Richard Carr

Posted

Yes me too! Necrobiotic xanthogranuloma seemed to fit all the clinico-pathological features best and there are some quite striking multinucleate cells. Patient had a longstanding MGUS and localised restriction on Kappa / Lambda. I did initially suggest NL until the clinicians revealed the MGUS which was not supplied on the request form so please don't blame me for being difficult! The patient was not diabetic. 

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Krishnakumar subramanian

Posted

Thanks for this case sir

are touton giant cells/cholesterol clefts needed or not necessary in diagnosis of NXG

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Dr. Richard Carr

Posted

They are seen in the classic cases but I guess there must be variants such as this that sit between stools.

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