Cases of Interest
Fig. 1. Cell phone photos by the patient's wife.
At presentation to the dermatologist, an 84-year-old male had a relatively asymptomatic but enlarging nodulo-ulcerative lesion on the left proximal forearm of 2.5 months' duration. It had evolved from one of several abrasions to the forearm sustained during a "slip and fall" in the garden in November 2009, as recorded by his wife on her cell phone camera at 5 and 14 days after (Fig. 1). No medical attention was sought at the time. The scrapes were merely cleaned with soap and water and then bandaged with gauze over Polysporin. The scrapes had almost completely healed two weeks after the accident (Fig. 1, right panel). While the scrapes continued to resolve, a single proximal wound enlarged into a 4-cm indurated ulcer. Seventy-six days after the accident continued deterioration of the proximal forearm wound prompted the patient's initial contact with the dermatologist (Fig. 2, upper left).
Fig. 2. Follow up photos by the dermatologist.
A few days later, a rubbery subcutaneous nodule was noticed on the upper-right inner breast. Apart from the elbow ulcer, the patient reported feeling well and had no history of exotic travel or other exposures and no risk factors for immune compromise. A melanoma, 0.2 mm thick, had been excised in 1996 from his back without sequelae. Of current medical concern was a rising PSA level in light of previous treatment for prostate cancer approximately 20 years ago involving radiation and 2 prostate needle biopsies of 12 September 2005 showing carcinoma with a Gleason score of 8/10. Peripheral neuropathy led to a protein electrophoresis in May 2007 revealing an M-spike in the gamma region comprising 1.34 gm% of IgG-kappa. A bone marrow biopsy in June 2007 yielded small populations of kappa-predominant lymphocytes and plasma cells consistent with either low level lymphoplasmacytic lymphoma or monoclonal gammopathy of undetermined significance (MGUS). In July 2007, he began rituximab bimonthly and has remained on it since then. His most recent rituximab dose was in the last week of March 2010. A chest x-ray was unremarkable.
The initial dermatologic impressions were basal or squamous cell carcinoma vs. lymphoma for the enlarging forearm ulcer and angiolipoma for the chest nodule. Biopsies of both lesions (arm and chest) showed similar lymphocyte-rich granulomatous inflammation at both sites favoring infection (backdrop, right figure, above). Birefringent soil contaminants showed up in the initial biopsy of the forearm lesion corroborating the history of an original injury in the garden. Mycobacterial and fungal cultures on material from biopsies of the forearm and chest lesions produced no growth. Empiric treatment was minocycline 100 b.i.d. and Clobex spray, while the forearm ulcer progressed in thickness and diameter (Fig. 2, right).
The brisk granulomatous inflammation displayed in the initial biopsy from forearm (background in Fig. 2) predicted infection. The recommendation to repeat the biopsy of the arm with provision for culture was met, plus a biopsy of the relatively new chest nodule. Again, a brisk, focally necrotic granulomatous inflammation was evident in both while special stains were negative for fungi and mycobacteria as were the cultures. Lacking a specific diagnosis, the indurated ulcer was excised 127 days after the accident (31 March 2010), providing abundant fresh material for microscopic study and culture, again without demonstrable fungi or mycobacteria and sterile for bacterial pathogens, mycobacteria and fungi. Diagnostic frustration motivated Rags on a 2-hour histologic scrutiny since “the answer must be here”.
Fig. 3. Histopathologic field from the excised ulcer (x600).
Your diagnosis is:
- Malakoplakia
- Malignant histiocytosis
- Rosai-Dorfman disease
- Prostatic carcinoma
- Langerhans histiocytosis
- Infection
A 49-year-old male had an injury 2 decades ago and recently developed nodular swelling of the distal index finger (Fig. 1). Procedure: Left index finger debridement. The resultant pink-tan 17 x 14 x 11-mm specimen was mottled by white chalky deposits. Microscopically, multinucleated giant cells contained pale yellow-green translucent material that was weakly birefringent (Fig. 2). Mononuclear histiocytes contained finely particulate material that appeared jet black under conventional transillumination (Fig 3).
Your diagnosis is:
- Gout
- Calcium pyrophosphate deposition disease
- Paint
- Pigmented giant cell tumor of tendon sheath
- Metastatic melanoma
An otherwise healthy 33-year-old woman gave a 6-week history of a left superolateral orbital mild tenderness, ptosis, proptosis, and diplopia on upgaze. MRI shows a superolateral orbital mass (Figs. 1 & 2). A biopsy was performed (Fig. 3).
This is:
- Spiradenoma
- Spiradenocarcinoma
- Spiradenocylindrocarcinoma
- Adenoid cystic carcinoma of the lacrimal gland
- Eccrine carcinoma
- Glandular schwannoma
- Metastatic carcinoma