UPMC Dermatopathology "Case of the Month" Presentations
UPP - Department of Dermatology, Dermatopathology Unit
Case Authors: Timothy Patton, DO, Douglas Kress, MD and Bong Kim, MD
AUGUST 2004 CASE OF THE MONTH
CLINICAL FINDINGS
CLINICAL HISTORY:A
48-year-old female presented with a recent history of oral, ocular, and genital
ulceration; right hip and leg pain; and fever. The patient had a history of
inflammatory bowel disease that was treated in the past with mesalamine and
corticosteroids. Prior to the onset of her presenting symptoms, she had discontinued
both the mesalamine and corticosteroids and had worsening of her gastrointestinal
symptoms, with the onset of diarrhea occasionally mixed with blood. Ambulation
had become difficult secondary to the right hip and leg pain as well as the
genital ulcerations. She was admitted to the hospital and taken to the OR for
debridement of the ulcers, and dermatology was consulted.
On exam she was afebrile
and appeared to be in mild discomfort. There was a 3 to 4 mm aphthous ulcer
on the right side of the tongue (Figure 1), as well as a conjunctival ulceration
on the right eye (Figure 2). In addition, there were multiple ulcerations present
in the perineum with an undermined border (Figure 3). An excisional biopsy was
performed on a smaller ulceration and sent for H & E evaluation as well as tissue
culture. A pathergy test was negative. An MRI of her right hip revealed an effusion
as well as adductor enhancement. Athrocentesis was performed on the right hip
effusion and sent for gram stain and culture.
Laboratory studies revealed a WBC of 17,000 cells/ l with 81% neutrophils. Hepatic and renal studies were within normal limits, and the results of blood and tissue cultures were all negative. The gram stain and culture of the right hip effusion was also negative. Biopsy of the lesion revealed ulcer with underlying dense neutrophilic and lymphohistiocytic infiltrate, with sparing of the epidermis (Figs. 4 and 5). There was a secondary vasculitis in the dermal and subcutaneous vessels with microthrombi in the small vessels (Fig. 6). No microorganisms were identified with special stains.
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