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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 4019 - 16 June 2022 Posted By: Saleem Taibjee

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"34F, intermittent rashes on arms and legs, pruritic and blistering. History of eczema, Coeliac disease. Examination shows tense blisters on torso, trunk and limbs"


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sfwenson

Posted

Needs DIF. Given the history of celiac I'd guess IgA-related dermatitis herpetiformis.

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Meenakshi Batrani

Posted

Seems like partly excoriated or re-epithelized blister. There are significant neutrophils in dermal papillae. Needs DIF. 

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Shawn

Posted

acrodermatitis enteropathica vs other nutritional deficiency. 

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Anil Patki

Posted

Psoriasiform hyperplasia and upper epidermal pallor suggest a nutritional deficiency dermatosis, a result of malabsorption. Pellagra, necrolytic migratory erythema are the possibilities apart from acrodermatitis enteropathica or multiple deficiencies. Clinicopathological correlation will be needed. 

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volha

Posted

Interesting case. Initially from low power my thoughts were TEN. then i could see neuts in the dermal papillae 

the history tense blisters and distribution not so characteristic on the DH alone, usually small vesicles ...

acrodermatitis enteropathica usually around mouth and perianal skin , pellagra should be diarrhoea 

so may be combined pathology TEN and DH?

so CPC and IMF i would say ...

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Krishnakumar subramanian

Posted

could it be necrolytic acral erythema

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Saleem Taibjee

Posted

Great discussion / thoughts on this case, and this confirms it was worthwhile including this case.

This case illustrates the pitfall of biopsy/histology of a late/old blister. As Meenakshi has recognised, this is actually a re-epithelialised blister, and this accounts for the peculiar appearance of the epidermis and even the false impression of intra-epidermal/superficial clefting.

I have seen similar cases. For example, I recall one case which was reported and presented at a meeting as an unusual case of toxic epidermal necrolysis, but in reality I am sure was bullous pemphigoid in which the late stage of biopsy accounted for necrosis of the overlying epidermis.

Volha has recognised that tense blisters are very rarely seen in Dermatitis herpetiformis which is another important point in this case.

The clinician's impression was of bullous pemphigoid despite the younger age, and sometimes BP can be neutrophil-rich. Direct immunofluorescence was typical, with linear C3 and IgG within the basement membrane region.

BW

Saleem

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volha

Posted

she is young for BP ...

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Saleem Taibjee

Posted

Yes, she is young for BP, but we do see cases.

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