UPMC Dermatopathology "Case of the Month" Presentations
UPP - Department of Dermatology, Dermatopathology Unit
Ellen Roh MD, Rana Rofagha MD, Laura Ferris MD
AUGUST 2007 CASE OF THE MONTH
CLINICAL FINDINGS
AF presented to the emergency department and was subsequently admitted for a painful left leg wound. She reported having the lesion for almost two years, which she had been treating with topical steroids, as she had previously been diagnosed with psoriasis. She denied having any joint pain, other lesions or a family history of psoriasis, but she did recall a preceding scratch in the area. Her past medical history was significant for epilepsy and hyperlipidemia but no malignancy or immunodeficiency. Her medications included topiramate, primidone and Vytorin. On admission, she was started on IV ampicillin/sulbactam, and our dermatology service was consulted.
Physical Exam:
Our patient’s vital signs were stable, and she appeared to be a well-nourished, comfortable African American female. There was a 6 x 10 cm verrucous plaque on her left anterior shin, with the inferior 1/3 necrotic (see figure 1). The lesion was extremely tender, and had minimal surrounding erythema. She had no palpable lymph nodes and no lesions elsewhere. No joint swelling or nail pitting could also be appreciated.
CBC WNL
Blood cultures negative
Wound culture: coagulase-negative staphylococci and diphtheroids
A wedge biopsy of the lesion revealed a pseudocarcinomatous epidermal hyperplasia with marked hyperkeratosis and neutrophilic debris (see figure 2). In the dermis, there was fibrosis and granulation tissue with a prominent neutrophilic infiltrate, as well as supportive granulomas (see figure 3). Some of these granulomas encased PAS-positive stellate crystalline formations, otherwise as the “Splendore-Hoeppli” phenomenon. Fite, AFB, GMS, treponemal and gram stains did not show any infectious organisms.
GO TO FIGURE AND IMAGE REVIEW PAGE