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 1870 - 28 July - Dr Richard Carr

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
Submitted Date :
   (0 reviews)

F65. Pervious history of low grade NHL with high grade transformation. Plaque on cheek.


User Feedback


urmilapandey

Posted · Report

wondering if there is vasculitis, don't know if the dense pink stuff is fibrin. patient may be immunocompromised (given the history) so stains for bugs; ? reaction to drugs. doesn't look like lymphoma to me but then i have little expertise in this area.

Share this comment


Link to comment
Share on other sites
Raul Perret

Posted · Report

My feeling was that the main pattern is that of an acute folliculitis with pustular formation and some lichenoid infiltrate. I would perform some serial sections, special stains for microorganisms, and of course check for herpes and other viruses. The lichenoid infiltrate puzzles me, that is why I think is wise to remark that a drug reaction cannot be discarded. There was this term used in the past: follicular toxic pustuloderma for some drug reactions but they are actually cases of AGEP, and as we know this is generalized and not localized like in this case.

Share this comment


Link to comment
Share on other sites
vincenzo polizzi

Posted · Report

What about an arthropod bite reaction in patient with Richter syndrome ( cll in DLBCL transformation )?

Share this comment


Link to comment
Share on other sites
Nitin Khirwadkar

Posted · Report

Definitely acute folliculitis. To rule out bugs. In addition there is almost an interface in images 3 & 5. Drug induced folliculitis?

Share this comment


Link to comment
Share on other sites
Admin_Dermpath

Posted · Report


Dear All 

Images 7- 11 added at the request of Dr Carr. 

DermpathPRO Admin

Happy Weekend!

Share this comment


Link to comment
Share on other sites
Saman Fatah

Posted · Report

Intra-epidermal collection of mixed inflammatory cell + necrotic keratinocytes overlying a clear folliculitis. At DEJ, the individual lymphocytes seems to be surrounded by a clear halo "lymph in holes" they are aligned along DEJ, I couldn't see convincing apoptosis at this level. 

If colleagues agree that this is interface/lichenoid, would appreciate if they elaborate on why? 

Infective cause is crucial to exclude especially herpes folliculitis in the current context. Aware IHC for HSV/VZV is an option but from Clinician point of view, viral swab from the plaque for PCR is  a sensitive and extremely easy to do with results in 1-2 days. 

Herpes infection is one of the well known lymphoma mimicker which may fit well with some of the changes in this biopsy. 

Share this comment


Link to comment
Share on other sites
Saman Fatah

Posted · Report

Just for record, I have seen the first 6 photomicrographs only when posted the earlier comment and my screen was no refreshed whilst busy with typing so was not really aware of them! 

Share this comment


Link to comment
Share on other sites
Admin_Dermpath

Posted · Report

Dr Richard Carr

Final Diagnosis: Herpes zoster folliculitis.

Share this comment


Link to comment
Share on other sites
Dr. Richard Carr

Posted · Report

Thanks Admin for posting the diagnosis (I was on leave). I thought this was a nice example of prominent necrotic follicular keratinocytes with sparse multinucleate cytopathic changes in keeping with VZV folliculitis. In fact the clinical was of numerous pustules erupting on the chest and face on an erythematous base with a large vesicular plaque on the cheek ?varicella zoster. This case demonstrates the pseudolymphomatous pattern (presumably exaggerated here due to immune suppression) and interface reaction pattern that can be seen and if you miss the follicular involvement or subtle cytopathic changes (both absent in re-cut sections) you may not make the diagnosis. Well done to those for thinking of zoster on the first set of images.

Share this comment


Link to comment
Share on other sites


Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now