Case Number : Case 792 - 1st July Posted By: Guest

Fibrinoid necrosis (glassy eosinophilic changes of vessel walls) with neutrophil-predominant perivascular inflammatory infiltrate. Lesser numbers of eosinophils and lymphocytes. Verrucous epidermal hyperplasia with no significant epidermal inflammatory changes.
As an isolated finger lesion, infection, insect bite reaction, pyoderma gangrenosum, or (for something exotic) [url="http://archderm.jamanetwork.com/article.aspx?articleid=478724"]Neutrophilic Dermatosis (Pustular Vasculitis) of the Dorsal Hands[/url] might be a consideration given combination of neutrophilic vasculitis and pseudocarcinomatous epidermal hyperplasia. If more widespread, then the clinical context, and/or serology and/or direct immunofluorescence studies may give additional clues.

In addition to very informative comment by Dr Davie,
what about erythema elevatum ditunium?Sprotrichosis?Verrucous tuberculosis?

Neutrophilic dermatosis of the dorsal hands

Neutrophilic dermatoses of the hands was my first thought histologically but the clinical does not entirely fit (not a single lesion). I would therefore rule out an infective aetiology with appropriate stains as suggested by Dr. Maria. If infections are included and this is a single lesion, EED would be on top of my differentials.

Given the history case of an isolated finger plaque in an elderly woman and the microscopic features of a leukocytoclastic vasculitis, I will favor Osler’s node or other cutaneous lesion caused by septic embolus or immune complex disease due to distant bacterial focus (e.g. acute meningococcal infection).

I’d like to invite my colleagues to join me in welcoming Dr. Hurt as our new Chief Editor of DermpathPRO.

Welcome Mark! [i] My first thought was EED.[/i]

[font=comic sans ms,cursive][size=4][b]Erythema elevatum diutinum[/b][/size][/font]

First thought EED, second thought: infection.

U r most welcomed Dr Mark,,,

I agree with EED. Welcome Dr. Mark.

I think the presence of leucocytoclastic vasculitis, with fibrin in vessel walls, neutrophils and nuclear dust, given the clinical context, are consistent with the diagnosis of erythema elevatum diutinum. Welcome Dr. Mark Hurt!