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 1893 - 30 Aug - 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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F60. Hypothyroidism, vulval lichen sclerosus, general aches & pains, fibromyalgia. Fixed rash outer thigh 3 years. No preceding h/o pustules / blister. Originally described as purpura by referring GP over an area 5 x 4cm forming red/brown macules. ?Lichen planus at presentation. DHx: Thyroxine, sertraline, amitryptylline, tramodol. Biopsied x3


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Raul Perret

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The differential dx is large, but I thought strongly about Lyme disease in this case. Did the "fibromyalgia" start after the skin lesions? Have to perform special stains in cases like this one, eventually PCR.

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Dr. Mona Abdel Halim

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The last image reminds me of Castleman's disease?? Hyaline vasclar type?? Might be wrong though!

 

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vincenzo polizzi

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Difficult case.  Histologically is consistent with Rosai-Dorfman Disease. Alternating  plasma cells rich dark areas and atypical histiocites rich light areas. The histiocytes are RDD typical cells. But there’s something disturbing: many eosinophils and Castleman like lymphoid follicles. And an odd clinical history.  

However agree with dermpath1   RDD is my first spot...surely the most difficult case of RDD I have ever seen (if am not wrong). 

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Anil Patki

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Nodular lymphoid infiltrates with plasma cells and eosinophils with angiocentric arrangement.Fibromyalgia, arthralgia and a fixed rash suggest lymphomatoid granulomatosis. Although lymphomatoid granulomatosis presents with nodules or plaques, macular lesions are also reported

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Robledo F. Rocha

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What do you think about IgG4-related disease? I don't have experience with cutaneous lesions.

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vincenzo polizzi

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What do you think about IgG4-related disease? I don't have experience with cutaneous lesions.

  • Ok Robledo.   Your thought is very interesting.   I thought of an association between RDD and IgG4-RD, after your comment.  Obliterative lymphocytic  phlebitis and abortive lymphoid follicles could be better justified!
  • But the eosinophils? So I started thinking of an association between RDD and LCH...So this case might be so confusing or is my mind a bit confusing?...The only clear thing for me is the component RDD-like

 

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Saman Fatah

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I thought about the possibility of cutaneous Castelman's disease vs cutaneous plasmacytosis, if one consider these separate entities.

It is rare in Caucasians, would be interesting to know results of serum protein electrophoresis and futher IHC plus complete staging for evidence of systemic disease.

Clinical picture of red/brown lesions is suggestive as well, especially macules and thin dermal plaques mainly. Site usually trunk but extremities can be involved.

Very interesting case, not sure if one "Spot diagnose"such cases!

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Robledo F. Rocha

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3 hours ago, vincenzo polizzi said:

What do you think about IgG4-related disease? I don't have experience with cutaneous lesions.

  • Ok Robledo.   Your thought is very interesting.   I thought of an association between RDD and IgG4-RD, after your comment.  Obliterative lymphocytic  phlebitis and abortive lymphoid follicles could be better justified!
  • But the eosinophils? So I started thinking of an association between RDD and LCH...So this case might be so confusing or is my mind a bit confusing?...The only clear thing for me is the component RDD-like

 

Dear Vincenzo, eosinophils can be found in the inflammatory infiltrate of IgG4-related disease. Indeed, eosinophils count per high power field can reach an amount as large as 289!

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Raul Perret

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It is funny that eosinophils are quite prominent in the first biopsy and then we barely see them in the following samples

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Sasi Attili

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No idea!! Some odd fixed lymphomatous drug reaction with eos?

 

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Dr. Richard Carr

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Some great suggestions. All accept RDD and Castleman's we already did consider!  Prof. Werner Kempf kindly performed PCR studies for Lyme and all the viruses we could think off (HSV/VZV, EBV etc), IgG4 was not particularly in excess. Our final conclusion was some sort of pseudolymphoma/reactive plasmacytosis akin to APACHE (the latter suggested by Werner). Sometimes skin cases are exceedingly frustrating and clearly given that the patient (who must think we are stupid) submitted to 3 biospies it's curious we cannot give a better answer!

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Sasi Attili

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11 hours ago, Dr. Richard Carr said:

Some great suggestions. All accept RDD and Castleman's we already did consider!  Prof. Werner Kempf kindly performed PCR studies for Lyme and all the viruses we could think off (HSV/VZV, EBV etc), IgG4 was not particularly in excess. Our final conclusion was some sort of pseudolymphoma/reactive plasmacytosis akin to APACHE (the latter suggested by Werner). Sometimes skin cases are exceedingly frustrating and clearly given that the patient (who must think we are stupid) submitted to 3 biospies it's curious we cannot give a better answer!

 

 

Wow! Thanks for the interesting case. Glad to know that others see such cases too. 

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Dr. Richard Carr

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Just now, Dr. Richard Carr said:

Thanks Sasi - Reactive cutenous lymphoid hyperplasia with plasmacytosis, APACHE-like (aetiology remains obscure).

 

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msofopoulos

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On 8/31/2017 at 20:30, Dr. Richard Carr said:

Some great suggestions. All accept RDD and Castleman's we already did consider!  Prof. Werner Kempf kindly performed PCR studies for Lyme and all the viruses we could think off (HSV/VZV, EBV etc), IgG4 was not particularly in excess. Our final conclusion was some sort of pseudolymphoma/reactive plasmacytosis akin to APACHE (the latter suggested by Werner). Sometimes skin cases are exceedingly frustrating and clearly given that the patient (who must think we are stupid) submitted to 3 biospies it's curious we cannot give a better answer!

Thanks!

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