Dermacon 2017

Slides for Pre-conference Workshop on Dermatopathology,
Thursday, January 11, 2017​

Click on the link below for the detailed Workshop schedule.
http://www.dermacon2017kolkata.com/workshop-on-dermatopathology.pdf

User Name: derm17| Password: derm17

Cases 1- 5 : Dr Sushil Pande

Case 1 : A 62-year-old woman with pigmented plaque over the face

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Diagnosis - Basal Cell Carcinoma

Hisopathological findings: Dermis shows well defined nodular masses or collection of basaloid cells with crowding of nuclei. There is fencing or ‘palisade-like’ arrangement of basaloid cells at the periphery of these masses. Basaloid cells are surrounded by ‘retraction spaces’ seen as clear clefts. Presence of melanin pigment amongst basaloid cell masses is suggestive of epidermal or epithelial origin of cells. Stroma surrounding these nodular masses is fibrovascular. Infiltrate is seen in the stroma. There are no mucin deposits.
Note:- Presence of pigment does not qualify for pigmented basal cell carcinoma as melanin pigment is a common finding in BCC seen Asian people.

Case 2 : A 32-year- old woman with multiple round, firm facial papules in mid-face area 

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Diagnosis - Trichoepithelioma

Hisopathological findings: There are collections of basaloid cells forming clusters some of them appears to be connected with overlying epidermis. There are no retraction spaces around these nodules. However, central cysts containing keratin is seen which are appreciated in lower magnification. There are no crowding of nuclei of these basaloid cells. No inflammatory infiltrate is seen

Case 3 : A 42-year-old woman with erosions in flexures

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Diagnosis - Hailey Hailey Disease

Hisopathological findings: The findings require careful examination under medium to high power. There is suprabasal cleft as seen in pemphigus vulgaris. Closer look shows round keratinocytes in the Stratum Malphigii almost in the full thickness of the epidermis. However, acantholytic keratinocytes are still attached to each other or holding each other. Appearance is classical but closest differential diagnosis is pemphigus vulgaris. Dermal changes are uncharacteristic

Case 4 : A 16-year-old young male with multiple rough papules in seborrheic areas

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Diagnosis - Darier’s Disease

Hisopathological findings: The findings require careful examination under low, medium and high power. At low power, there is acanthosis and papillomatosis of the epidermis. At higher magnification, suprabasal cleft in papillomatous epidermis is seen. Closer look shows eosinophilic cells with eccentric pyknotic nucleus. Such cells are predominantly seen in Stratum spinosum and granulosum. Higher up in the epidermis, round cells with plump keratohyaline granules appearing granular. Dermal changes are uncharacteristic.

Case 5 : A 38-year-old woman with pigmented macules in malar area of the face

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Diagnosis - Ochronosis

Hisopathological findings: Epidermis shows flattening or blunting of rete ridges. The findings require careful examination under medium and high power. At medium power, in the papillary dermis, there are blunt ended and slightly ‘curvilinear’ and thickened collagen bundles. As against normal homogenous eosinophilic color typical of collagen tissue, collagen bundles appears yellowish brown. Melanophages are also seen. Infiltrate is minimal

Cases 6- 10 : Dr Meenakshi Batrani

Case 6 : A 19 month male child with crusted papules and plaques involving scalp, face, groins and perianal region 

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Diagnosis - Langerhan’s Cell Histiocytosis

Hisopathological findings: Broad band like upper dermal infiltrate is present obscuring the dermo-epidermal junction and infiltrating the epidermis covered with parakeratotic scale crust. The infiltrate is composed of uniform large cells having abundant pale eosinophilic cytoplasm with central to eccentric reniform vesicular nuclei, with, few admixed eosinophilis

Case 7 : 50 year female with eczematous lesion on right nipple

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Diagnosis - Mammary Paget’s Disease

Hisopathological findings: Acanthotic epidermis shows full thickness permeation by single and small nests of large round cells having abundant pale eosinophilic to clear cytoplasm with large vesicular nucleus having 1-2 nucleoli. Rare duct like structure can be recognized on careful search

Case 8 : 50 year female hyperpigmented macule since 12 years. Rapid increase in size since last two years. O/E: Single 6x7mm sized, variegated hyperpigmented macule with irregular margins

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Diagnosis - Malignant Melanoma in Situ

Hisopathological findings: Broad, asymmetric, uncircumscribed, junctional melanocytic lesion composed of confluent proliferation of atypical melanocytes. There is prominent pagetoid spread with epidermal effacement/consumption. Melanocytes show cytological atypia in the form of vesicular pleomorphic nuclei with nucleoli. Fibrosis, patchy band like lymphocytic infiltrate and numerous melanophages are seen in papillary dermis

Case 9 : 46 year presented with a long standing papule on left thigh. In last 9 months, the lesion has rapidly increased in size to form a 7x6cm plaque

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Diagnosis - Porocarcinoma

Hisopathological findings: Intraepidermal tumor is seen in the form of discrete nests and few single cells at various levels in acanthotic epidermis. The tumor is infiltrating upto upper reticular dermis in the form of variable sized lobules and nests. Surrounding stroma shows horizonatally parallel fibrosis and perivascular lymphocytic infiltrate with few eoisnophils. The individual tumor cells are small cuboidal to large squamoid cells with dyskeratosis and few cells showing clear cell change. Nuclei are large, highly pleomorphic, vesicular with prominent nucleoli and numerous atypical mitotic figures. An occasional duct like structure can be noted on careful search

Case 10 : 51 year male with 10 year history of erythematous to hyperpigmented, mildly pruritic and slightly scaly large patches on trunk, and both upper/lower limbs

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Diagnosis - Mycosis Fungoides

Hisopathological findings: Thickened parakeratotic stratum corneum covers the epidermis showing psoriasiform hyperplasia. Solitary lymphocytes with perinuclear halo and having slightly larger and hyperchromatic nuclei are seen extensively infiltrating the epidermis in the absence of associated spongiosis, more prominently involving lower one third and tagging the basal layer. Few epidermotropic lymphocytes have indented/irregular nuclear contour. An occasional tiny intraepidermal collection of atypical lymphocytes consistent with Pautrier’s microabscess is to be noted. Papillary dermis shows moderately dense band like lymphocytic infiltrate with perivascular accentuation and coarse collagen bundles.

Cases 11- 15 : Dr Sasi Attili

Case 11 : 40/F with multiple papules, vesicle, bullae and few tense blisters some flaccid blisters on an erythematous background. Few healing with eschar formation. H/O: Vesicle and bulla eruptions at site of injections

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Diagnosis - Leukocytoclastic Vasculitis (Bullous)

Hisopathological findings: There is a large intraepidermal vesicle present centrally, with the cavity bearing numerous neutrophils and RBC. The base of blister is composed of necrotic basal keratinocytes. Within the upper-mid dermis, there is a moderately dense perivascular and interstitial inflammatory infiltrate composed predominantly of neutrophils. The dermal capillaries appear 'sick' with fibrinoid vessel wall necrosis and intramural fibrin. Numerous neutrophils are seen within the vessel walls, associated with extravasation of RBC into the interstitium and mild karyorrhexis

Case 12 : A 37/F with vulval pruritis and dyspareunia

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Diagnosis - Lichen Sclerosus

Hisopathological findings: The epidermis displays atrophy, parakeratosis and mild spongiosis. There is a band of papillary dermal sclerosis underpinned by a dense lymphocytic infiltrate in the upper/ mid dermis. Focal vacuolar interface change is noted. A few dilated capillary loops are seen in the papillary dermis

Case 13 : 26/F with a large inurated plaque over right arm of 2-3 months duration. Skin over plaque- pigmented & shiny. There are similar subcutaneous nodules (developing) over right arm & right buttock. In addition there are healed large atrophic plaques over both cheeks

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Diagnosis - Morphoea with Dystrophic Calcification

Hisopathological findings: The collagen in the deep dermis and interlobular septae (fat) demonstrates early sclerosis, associated with a perivascular lymphohistiocytic infiltrate. There is a septal panniculitis with the inflammatory infiltrate spilling over into the lobules. The septae appear thickened. Focally in the deeper fat lobules there is a large area of dystrophic calcification surrounded by a histiocytic infiltrate

Case 14 : 54/F with pigmented patches on the face

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Diagnosis - Lichen Planus Pigmentosus

Hisopathological findings: Mild epidermal atrophy, associated with a band like lichenoid infiltrate and numerous melanophages. No basement membrane thickening, deeper infiltrate/ mucin to suggest DLE. But do note that FDE, DLE and LPP share similar histological features and can be impossible to distinguish on histological grounds alone. CPC +- DIF essential

Case 15 : 56/F, diabetic with a 1yr h/o multiple erythematous annular lesions with central clearing over the dorsum of hand, feet & trunk

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Diagnosis - Interstitial Granuloma Annulare

Hisopathological findings: The epidermis appears relatively normal. The dermis appears ‘busy’ with a moderately dense perivascular and interstitial lymphohistiocytic infiltrate. Lymphocytes and histiocytes are seen infiltrating between the collagen bundles, which appear separated apart. Focal swelling and degeneration of collagen fibers is seen. A few plasma cells are seen in the interstitium, associated with a tinge of bluish strands (suggestive of interstitial mucin)

Cases 16- 20 : Dr Dipankar De

Case 16 : HIV seropositive patient having persistent non-healing ulcer

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Diagnosis - Persistent Orolabilal Herpes

Histopathologic findings: Mild acanthotic epidermis. Separation at dermo-epidermal junction. Dense neutrophilic infiltrate in the dermis. Enlarged separated keratinocytes with ground-glass appearance and multi-nucleation

Case 17 : Persistent psoriasiform plaque for 3 years

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Diagnosis - Bowen’s Disease

Histopathologic findings: Full thickness dysplasia with nuclear disarray giving rise to wind- blown appearance. There are several mitotic figures and apoptotic keratinocytes. Basement membrane is intact. Few mature lymphocytes can be observed in the epidermis. However, there is dense lymphocytic infiltrate in the superficial dermis

Case 18 : Maculopapular rash in a post- allogenic bone marrow transplant patient

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Diagnosis - Graft-Versus-Host Disease

Histopathologic findings: Flattened rete pegs. Occasional follicular plugs. Mild peri-vascular lymphoytic infiltrate in superficial dermis. RBC Extravasation. Apoptotic keratinocytes.

Case 19 : Flat hypopigmented papules along with lichenoid papules on sun-exposed areas

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Diagnosis - Epidermodysplasia Verruicformis

Histopathologic findings: Acanthotic epidermis with large keratinocytes predominantly in the granular layer of epidermis whereas lower layers of the epidermis is relatively spared. These enlarged keratinocytes have vesicular nuclei and basophilic cytoplasm. Prominent nucleoli can be observed

Case 20 : Male patient of hidradenitis suppurativa developed painful urticarial plaques on extremities following third dose of adalimumab

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Diagnosis - Eosinophilic Cellulitis

Histopathologic findings: Acanthotic epidermis with spongiosis. Dermal edema with plasma accumulation in places. Dense eosinophilic infiltrate throughout whole thickness of dermis extending upto the subcutaneous fat leading to nodular collection of eosinophils. Several eosinophilic flame figures can also be observed. Leukocyte of non-eosinophilic lineage is virtually absent

Cases 21- 25 : Dr Yu-Hung Wu

Case 21 : A 26 year old woman with papules on her axilla

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Diagnosis - Xanthomatous Fox-Fordyce Disease

Histopathologic findings: There is a plug in the dilated hair follicle. Many foamy histocytes are present and surround the hair follicle. A small apocrine duct is noted and inserted into the follicular epithelium

Case 22 : A 3 days old female newborn has a plaque on the back

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Diagnosis - Subcutaneous Fat Necrosis of Newborn

Histopathologic findings: The epidermis and dermis are relatively normal. There is a lobular panniculitis. Lipophagic fat necrosis and multinucleated giant cells are present in the fat lobules. Radially arranged needle-shaped crystal or clefts are seen in some adipocytes and/or surround by histiocytes.

Case 23 : A 53 year old man has an eroded plaque on right forearm

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Diagnosis - Calciphylaxis

Hisopathological findings: The epidermis is partially eroded. There is a diffuse calcification in the dermis and subcutis with eccrinhe glands and adipocytes necrosis. The blood vessels are ectatic in the upper dermis but the perivascular inflammation is mild. Some blood vessels have calcium deposition in their walls.

Case 24 : A 51 year old man with a large verrucous plaque on his forearm

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Diagnosis - Squamous Cell Carcinoma-Like Pyoderma Gangrenosum

Hisopathological findings: There a marked irregularly downward proliferation of the epithelium into the deep dermis. Some scattered dyskeratotic keratinocytes are noted is the epithelial islands. The stroma is densely fibrotic and has mixed cell diffusely infiltration, including neutrophils, lymphocytes, histiocytes, plasma cells, and multinucleated giant cells.

Case 25 : A 44 year old man with a plaque on left cheek

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Diagnosis - Nodular Amyloidosis

Hisopathological findings: There is a diffuse deposition of amourphous eosinophilc materials in the whole reticular dermis. Lympho-plasma cells perivascular infiltration is present. The blood vessels, eccrine glands, and some adipocytes are thickened due to the pinkish deposited materials

Cases 26- 30 : Dr Wayne Grayson

Case 26 : 42-year-old female. Multiple elevated vascular skin lesions, present mainly on the trunk

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Diagnosis - Pyogenic granuloma (multiple eruptive pyogenic granulomas)

Histopathologic findings:There is a non-ulcerated, banal lobular intradermal proliferation of capillary vessels, each lined by a monolayer of plum endothelium. Occasional larger “feeder” vessels are observed near the base. Five additional skin lesions removed simultaneously showed similar histological features

Case 27 : 27-year-old man. Multiple vascular lesions, present on the trunk, limbs & face

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Diagnosis - Bacillary angiomatosis (bearing a close resemblance to a pyogenic granuloma.

Histopathologic findings: This excisional punch biopsy shows an intradermal capillary vascular proliferation with conspicuous peripheral epidermal collarette formation. On closer inspection, however, there are intervening granular, amphophilic extracellular colonies of bacterial organisms.

Case 28 : 34-year-old woman with multiple skin lesions, predominantly on the limbs.

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Diagnosis - Kaposi sarcoma (pyogenic granuloma-like variant)

Histopathologic findings: There is a small, slightly elevated superficial intradermal spindle cell vasoproliferative lesion. The entire lesion is enveloped by a peripheral epidermal collarette. A conspicuous background plasma cell-rich mononuclear inflammatory cell infiltrate is present.

Case 29 : 39-year-old female. Scattered small vascular skin lesions on the trunk

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Diagnosis - Glomeruloid Haemangioma

Histopathologic findings: The dermis in this punch biopsy is punctuated by multiple small clusters of delicate capillary vessels, many of which exhibit a distinctly glomeruloid architecture. The vessels are lined by plump endothelium. A striking feature is the presence of numerous eosinophilic globules. What is the underlying condition which should be excluded in this patient?

Case 30 : 3-year-old boy. Biopsy of vascular lesion on the thigh

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Diagnosis - Tufted Angioma

Histopathologic findings: This bisected punch biopsy shows a dermis and superficial subcutis punctuated by a vascular proliferation comprising multiple small clusters of capillary vessels, with a resultant “cannonball”-like low-power appearance. Some of these foci are flanked by displaced crescentic lymphatic channels. Which associated syndrome might this patient have?

Bonus Cases

(These cases are for self-study and will not be discussed at the workshop.)

Bonus cases 1- 2 : Contributed by Dr Yu-Hung Wu

Bonus Case -1 - 23011 – YH

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Diagnosis - Methotrexate Induced Interface Dermatitis

Bonus Case-2 - 23160 - YH

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Bonus cases 3- 4 : Contributed by Dr Sushil Pande

Bonus Case-3 - 216 – SP

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Bonus Case-4 - 273 – SP

 

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Bonus cases 5- 6 : Contributed by Dr. Wayne Grayson

Bonus Case-5 - 14-year-old boy. Pigmented skin lesion excised from the upper back.

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Hobnail Haemangioma (targetoid haemosiderotic haemangioma)

Histopathologic findings: The mid- to upper dermis is occupied by a wedge-shaped vascular proliferation, whose base is orientated towards the epidermis. The more superficial vascular spaces are congested, and are lined by a monolayer of plump, hobnail-like endothelial cells. The deeper dermal component is more subtle, with dissection of the dermal collagen by narrower vascular channels. On closer inspection, intervening deposits of haemosiderin pigment are seen

Bonus Case-6 - 28-year-old woman.Mass excised from the vicinity of the left ankle.

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Diagnosis - Retiform Haemangioendothelioma

Histopathologic findings: The dermis shows a vascular proliferation composed of elongated and arborizing vascular spaces, with dissection of intervening collagen bundles. In areas, the low-power appearances are distinctly reminiscent of the rete testis. Projecting into the lumens of the vascular channels are plump, hobnail-type endothelial cell nuclei