UPMC Dermatopathology "Case of the Month" Presentations
UPP - Department of Dermatology, Dermatopathology Unit
Case Authors: Joanne Simpson MD, MPH, Larissa Geskin MD, Drazen M. Jukic, MD, PhD
JUNE 2005 CASE OF THE MONTH
CLINICAL FINDINGS
56-year-old white male with a 10 month history of persistent generalized pruritic erythematous plaques, concentrated on mid abdomen, chest, and back. The patient was seen first nine months after the onset of this eruption in the general dermatology clinic. A skin biopsy was taken at that time to rule out Grover's disease versus Pityriasis Lichenoides et Varioliform Acuta (PLEVA) versus bites versus dermal hypersensitivity and was inconclusive, but suggestive of Grover's disease. Despite treatment with topical steroids, his lesions persisted. The patient was referred to our Contact Dermatitis clinic to be evaluated for allergic dermatitis, however no identifiable allergens were detected. Several weeks following patch testing, the eruption became more pruritic. The patient returned for evaluation and a repeat skin biopsy was performed to again rule out Grover' s versus lymphomatoid papulosis..
Physical Exam
On examination, the patient had multiple erythematous papules, some with overlying excoriations, on his legs, chest, abdomen, and back. [See: FIGURE 1].
Histopathology
The initial biopsy demonstrated a moderately dense dermal infiltrate of mostly small but occasional large lymphoid cells admixed with histiocytes, neutrophils and few eosinophils with varying degrees of acantholysis and focal dyskeratosis. [Figure 2]
The repeat biopsy showed epidermal hyperplasia seen akin to seborrheic keratosis with foci of spongiosis and dyskeratosis, which by itself would be suggestive of Grover' s disease. However, there were numerous CD30+ large lymphocytes (also CD7, CD3, and CD5 positive and CD20 negative) seen in the dermis and epidermis. There was also prominent margination of neutrophils in the blood vessels with plump endothelium and eosinophils in the background. The changes, taken together with re-reviewed previous eosinophils in the background. The changes, taken together with re-reviewed previous case were deemed most suggestive of lymphomatoid papulosis (type 3A4). [Figure 3]
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