Clinicopathologic Self- Assessment Melissa Piliang, MD Cleveland Clinic Dermatology and Pathology
Clinicopathologic Self-Assessment
Melissa Piliang, MD
Cleveland Clinic
Dermatology and Pathology
Case 1
Biopsy showed:
• Scalp:• Perifollicular inflammation with
interface dermatitis
• Face:• Interface dermatitis with extensive
melanoderma
Diagnosis?
A. Acne
B. Seborrheic dermatitis
C. Lichen planopilaris
D. Lichen planus pigmentosa
E. C and D
Lichen Planopilaris and Lichen Planus Pigmentosa• Treatment:
• Topical steroids
• Oral prednisone
• Hydroxychloroquine
Persistent Rash and Extreme Pruritus
• Added:• Methotraxate
• Azathioprine
• Antihistamines
Still Miserably Itchy….
• What would you do next?A. Add azathioprine
B. Add doxepine
C. Do another biopsy
D. Admit to hospital
E. Tell him it is all in his head
‘Itch Crisis’
• After many phone calls
• Went to ER (on his own)
• Admitted for ‘itch crisis’ with goal ‘to control itch’
• Another biopsy was performed….
Crusted (Norwegian) Scabies
• All immunosuppressants stopped
• Treatment:• Permethrin -> x2, 1 week apart
• Ivermectin -> x2, 2 weeks apart
Outcome
• LP Pigmentosa faded
• Itch dramatically improved
• Persistant• Mild scalp itch
• Scalp dermatitis
• Repeat scalp biopsy -> LPP without scabies
Clinical Infectious Diseases. 54(6):882;2012
Key Points
• Itch crisis? Think scabies
• Patients can have 2 things
• Scrape!
• Biopsy (and re-biopsy) diseases that fail to respond to treatment
• Scabies is a humbling disease to treat
Case 2
• 70 year old man
• Rheumatoid arthritis • Low dose prednisone
• Granular cell leukemia (in remission)
• Admitted for tender erythematous rash on arm
• Rapidly spread to all extremities
• Condition deteriorated• Fever
• Confusion
• Transferred to ICU
Blood Culture
• ‘Yeast’
What category of infection is most likely?
A. Bacteria
B. Fungus
C. Protozoa
D. Algae
E. Candida
What category of infection is most likely?
A. Bacteria
B. Fungus
C. Protozoa
D. Algae
E. Candida
Protothecosis
• Localized or disseminated infection
• Algae
• Sporangia are thick walled spherical bodies often in cytoplasm of giant cells
• Many internal septations with endospore • Classic morula appearance
• Nonbudding
• Prominent wall
• Inflammation may be sparse
PAS
The Lesson
• Always biopsy!
• Tissue cultures!
Case 3
• 30 year old man
• 6 month h/o oral ulcers
• Weight loss
• Felt unwell
• Unable to eat due to pain
History
• Prior outside biopsy showed acute and chronic granulomatous infiltrate
Next step?
A. Start prednisone
B. ANCA’s
C. Tissue culture
D. Repeat biopsy
E. CT chest
Reasonable next steps include all of the following except?A. Start prednisone
B. ANCA’s
C. Tissue culture
D. Repeat biopsy
E. CT chest
Reasonable next steps include all of the following except?A. Start prednisone
B. ANCA’s
C. Tissue culture
D. Request special stains
E. CT chest
History
• Working dx: Granulomatosis with Polyangiitis (formerly Wegener’s granulomatosis)
• Treated with high dose prednisone (40-60 mg daily)
Work-up - Positives
• Leukopenia
• Anemia
• T-cell deficiency
• Hypoalbuminemia
• Endoscopy – superficial esophageal erosions
Which test is more likely to lead to diagnosis?
A. HIV
B. CT scan head, neck, chest
C. Bone marrow biopsy
D. Skin biopsy with tissue culture
E. ANCA’s
Which test is more likely to lead to diagnosis?
A. HIV
B. CT scan head, neck, chest
C. Bone marrow biopsy
D. Skin biopsy with tissue culture
E. ANCA’s
Work-up - Normal
• HIV negative – multiple times
• Blood cultures – negative
• CXR – normal
• Imaging – showed ulcers, but no lesions outside oral/nasal cavity
• Renal function – normal
• ANCA’s negative
Histoplasmosis
Organisms surrounded by clear space Packed in histiocytes2 to 5 μm in diameter Thick cell wall GMS + and PAS +
Histoplasmosis
Further Work-up
• Bone marrow biopsy• Histoplasmosis
• Esophageal biopsy• Histoplasmosis
• Tissue culture• Histoplasmosis capsulatum
Treatment
• Amphotericin B
• Intraconazole
Histoplasmosis
• Airborne pathogen
• Inhalation of spores
• Soil contaminated with bat or bird excrement
• Farmers, gardeners, construction workers, HVAC, cave explorers
• Ohio River Valley: OH, IN, MO, MS (+ skin tests in 80% of population)
3 Forms
• Acute or primary: – Flu-like symptoms
– Most recover without treatment
– Many unaware of infection
• Chronic: – Pulmonary
– Can be fatal
• Disseminated: – Extra-pulmonary involvement
– Often fatal
Histoplasmosis
• Calcified lung nodules, similar to TB
• Fibrosing mediastinitis
• Ocular involvement: • Scarring of retina
• Subretinal hemorrhage
• Leads to blindness (like macular degeneration)
Key Tips
• Histoplasmosis often causes oral ulcers
• Beware neutrophilic (acute, suppurative) and granulomatous inflammation – Ask for special stains!
• The majority of patients unaware of exposure
Thank You pilianm @ccf.org