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Case Number : Case 1849 - 29 June - Dr Arti Bakshi Posted By: Guest

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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Clinical History: 70M, Longstanding widespread itchy rash, trunk and limbs.

Case Posted by Dr Arti Bakshi


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Admin_Dermpath

Posted

Dr Arti Bakshi's final case for June is a lovely set of images.

Geoff Cross - DermpathPRO Projects

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Dr. Mona Abdel-Halim

Posted

Is the patient on chemotherapy? 

The epidermis looks dysmatured, together with interface changes and necrotic KCs. Thinking of chemotherapy induced drug reaction with epidermal dysmaturation?? 

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Mariantonieta Tirado

Posted (edited)

Drug reaction: lichenoid inflammatory infiltrate with junctional necrotic keratinocytes. Good age, described as a rash, though limited to lower limbs. Previous comment valid for picture 1 and 3.

Edited by Mariantonieta Tirado

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Anil Patki

Posted

It's a longstanding rash. Pityriasis lichenoids chronica

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vincenzo polizzi

Posted

I was thinking of a Lichenoid Drug Eruption, too, but struggling with reactive keratinocytic atypia...the Mona’s one is a good suggestion...Chemiotherapic effect would fit well!

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Raul Perret

Posted

I also thought of a drug induced lichenoid reaction for CPC

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Saman Fatah

Posted

Lichenoid tissue reaction pattern with cell death above the basal layer. LDE or SCLE (including the drug-induced variants such as PPIs, Terbinfaine, various chemotherapy agents etc..). Careful drug history and clinical correlation is essential. One of the pitfalls of the LDE is a relatively long latency period compared to other commoner adverse cutaneous drug reactions and even the recovery can be slow on withdrawal.

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Arti Bakshi

Posted

All good differentials but nobody has reached the diagnosis (as yet!). The patient was not on any chemotherapeutic drugs. He was on a number of medications, but the rash predated all the drugs. The description of the findings is spot on...there is clearly a lichenoid reaction and also epithelial atypia/dysmaturation (well spotted Mona!)

Will ask Geoff to post some more images tomorrow....

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Raul Perret

Posted

GVH? I find the case difficult just based on these images as this pattern can overlap with many pathologies

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vincenzo polizzi

Posted

Secondary Syphilis? But doesn't clinically fit ( SS is a non-itchy rash usually ). Atypical Scabies? This is really a difficult case!!!

I'm looking forward to see the new images...

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Arti Bakshi

Posted

Have added 6 new images. The patient had 3 sets of biopsies. The initial images were from the first 2 and the last 6 are from his 3rd bx.

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Raul Perret

Posted (edited)

Is it regenerative hyperplasia, can this be something like paraneoplastic pemphigus? do we have immunofluorescence?

Edited by Raul Perret

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Saman Fatah

Posted

Lichenoid pattern + predominantly suprabasal acantholysis. PNP is reasonable to consider, however the history says longstanding rash and we do knot know if there is mucositis or not which is a cardinal feature in PNP. Interesting to see how this case evolves especially DIF results. In some places the parakeratosis is very confluent which could be seen in variety of nutritional deficiency dermatoses.

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vincenzo polizzi

Posted

The pattern is that of Actinic Keratosis, acantholitic and Lichenoid variant, and there is solar elastosis in dermis, but doesn't fit with trunk involvement and multicentric expression. 

Disseminated superficial actinic porokeratosis is another thought, but cellular atypic changes don't fit well.

An odd disseminated variant of Lichenoid Actinic Keratosis is my favorite spot...

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Dr. Mona Abdel-Halim

Posted

Based on the new images, I go for disseminated AK. 

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Saman Fatah

Posted

Last shot, how about multiple LPLK/BLK on a background of heavily sun damaged skin?

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manunoatay

Posted

Proliferating actinic keratosis with lichenoid inflammation...

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Arti Bakshi

Posted

This patient had 3 biopsies one of which was reported as drug reaction, one as PLC and one actinic keratosis. Pleased to see that all 3 differentials were considered by you guys as well! But the clinicians were (expectedly) not happy with 3 different diagnoses, none of which fit the clinical!! 

The rash was in sunprotected and sun exposed site, so Actinic keratosis by itself could not explain the findings. Drug reaction was excluded based on clinical history. Patient was otherwise fit and well and the rash had been present for years, so paraneoplastic pemphigus  didnt fit either. The rash did not have the reticulate/linear distribution of KLC and there was no facial involvement.

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Arti Bakshi

Posted

The histology is that of a mixed lichenoid, dysmaturative and acantholytic pattern. Combining this with a widespread itchy papular rash in a male, our diagnosis was GROVERS DISEASE. 

See link: https://www.ncbi.nlm.nih.gov/pubmed/20526170

This article details the new variants of Grover's disease and there was an excellent talk by the author in the LDS meeting in London last year. They have described 5 new variants including lichenoid, dysmaturative, porokeratotic, lentiginous and vesicular. It is really well worth a read. Interestingly, many of their cases with the dysmaturative pattern were misdiagnosed as actinic keratosis. They only included cases in their series where acantholysis was identified (which may be quite focal), but potentially one could have biopsies without acantholysis. Therefore, its worth remembering the new patterns, particularly in the clinical setting of Grover disease. I have since seen another case with a mixed lichenoid and acantholytic pattern, with interface dermatosis dominating the picture (and only very focal acantholysis)!

Thanks for all your comments.

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Arti Bakshi

Posted

Am J Dermatopathol. 2010 Aug;32(6):541-9. doi: 10.1097/DAD.0b013e3181c80cf9.
 
Grover disease: a reappraisal of histopathological diagnostic criteria in 120 cases.

Abstract

Grover disease (GD) is a rather common papular pruritic dermatosis that can be transient, persistent, or asymptomatic. The microscopic diagnosis of clinically suspected lesions can be challenging because GD can adopt different patterns, and involved areas are generally admitted to be mostly focal. The histopathologic hallmark of the disease is acantholysis, frequently combined with dyskeratosis, which confers the lesions an appearance similar to Darier disease, Hailey-Hailey disease, or pemphigus. Eczematous features can be observed as well. In this study of 120 consecutive cases of GD, we have found a sex and age incidence similar to what has been previously described, with no obvious seasonal influence, but careful evaluation of their microscopic features suggests that the histopathological diagnostic criteria of GD should be expanded. Specifically, in addition to the commonly described GD findings, we have detected cases with porokeratosis-like oblique columns of parakeratosis, lesions showing a nevoid or lentiginous silhouette, intraepidermal vesicular lesions, lichenoid changes with basal vacuolization and dyskeratosis, and dysmaturative foci with keratinocyte atypia. Moreover, quite often the dermal infiltrate was composed not only of lymphocytes intermingled with eosinophils, but also of neutrophils. In many cases, the capillary vessels showed hints of vascular damage including endothelial tumefaction due to cytoplasmatic edema and erythrocyte extravasation. Finally, because involved areas were larger than 2 mm in more than 50% of our cases, we should assume that GD lesions are not always as small as commonly claimed. Awareness of the patterns newly described herein may be important to avoid underdiagnosis of GD and may contribute to understand the pathogenesis of this acantholytic disease.

 

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Dr. Mona Abdel-Halim

Posted

Fascinating case Arti :-)

Thank you so much for sharing this case with us.. 

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vincenzo polizzi

Posted

Wow! Today I learned more than in a month of intensive study. 

Thanks Arti.  

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