Download - Case 13 - University of Leeds
![Page 1: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/1.jpg)
Case 13
Female 85. Recurrent urinary tract infections, and rash over fingers and dorsal thumb.
The best diagnosis is:
A. Pyodermatitis /Pyostomatitis vegetans
B. Neutrophilic dermatosis of the dorsal hands
C. Squamous cell carcinoma
D. Atypical mycobacterial infection (M.chelonae)
![Page 2: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/2.jpg)
Case 13Female 85. Recurrent urinary tract infections, and rash over fingers and dorsal thumb.
![Page 3: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/3.jpg)
![Page 4: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/4.jpg)
![Page 5: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/5.jpg)
![Page 6: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/6.jpg)
![Page 7: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/7.jpg)
![Page 8: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/8.jpg)
Case 13
Female 85. Recurrent urinary tract infections, and rash over fingers and dorsal thumb.
The best diagnosis is:
A. Pyodermatitis /Pyostomatitis vegetans
B. Neutrophilic dermatosis of the dorsal hands
C. Squamous cell carcinoma
D. Atypical mycobacterial infection (M.chelonae)
![Page 9: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/9.jpg)
Courtesy K Semkova & W Rickaby
Neutrophilic dermatosis of the dorsal hands – another case –subepiodermal oedema like in Sweet’s
![Page 10: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/10.jpg)
Focal leukocytoclastic vasculitisCommoner in neutrophilic dermatosis of dorsal hands than Sweet’s
Courtesy K Semkova & W Rickaby
![Page 11: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/11.jpg)
Neutrophilic dermatosis of dorsal hands
• also palms/fingers cf widespread in Sweet’s syndrome• Rarely systemic unlike Sweet’s• Like Sweet’s associated with underlying conditions includinginfection (UTI commonest as in this case) and malignancy
• Leukocytoclastic vasculitis commoner than Sweet’s
![Page 12: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/12.jpg)
Rook’s Textbook of Dermatology 9th ed (Wiley): Neutrophilic dermatoses differential diagnoses
• Pyoderma gangrenosum and variants
– classical ulcerative
– parastomal, pustular, bullous
– granulomatous superficial PG
– Neutrophilic dermatosis of the dorsal hand
– Extracutaneous PG
• Sweet’s disease & variants
– Neutrophilic dermatosis of the dorsal hand (Favoured to be Sweet’s variant rather than PG)
– Subcutaneous Sweet syndrome
– Histiocytoid Sweet syndrome
![Page 13: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/13.jpg)
Rook’s Textbook of Dermatology 9th ed (Wiley): Neutrophilic dermatoses
• Bowel-associated dermatitis arthritis syndrome
• Subcorneal pustular dermatosis (Sneddon-Wilkinson)
• Other neutrophilic dermatoses and variants:
– Pyodermatitis-pyostomatitis vegetans
– Antimicrobial pustulosis of the skin folds
– Aseptic abscess syndrome
![Page 14: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/14.jpg)
Rook’s Textbook of Dermatology 9th ed (Wiley): Autoinflammatory diseases
• periodic fevers;
• cryopyrinopathies;
• familial Mediterranean fever; TRAPS; CAPS; CANDLE; DIRA;
• DITRA; PAPA;
• Schnitzler syndrome;
• adult-onset Still disease
![Page 15: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/15.jpg)
Courtesy Lynne Jamieson
• Male 25 with Crohn’s disease for 4 years
• Six week history of oral ulceration with cobblestone oral mucosa and confluent pustules on lips, associated with confluent vegetative plaques (mildly exudative) in the groin (bilaterally), mons pubis and perineum
Differential diagnosis:Pyodermatitis /Pyostomatitis vegetans
![Page 16: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/16.jpg)
Courtesy Lynne Jamieson
Histopathological features: • Pseudoepitheliomatous hyperplasia • Intraepithelial / subepithelial abscesses
containing large numbers of eosinophils • Acantholytic keratinocytes
• Direct and indirect IMF: Negative
Pyodermatitis /Pyostomatitis vegetans
Clinical course tends to run parallel to that of the IBD
![Page 17: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/17.jpg)
• ? excessive immune response to gut bacteria• 1-6 years following bowel bypass surgery.• Recurrent episodes of fever, myositis• Non-destructive polyarthritis, tenosynovitis
Bowel-associated dermatitis-arthritis syndrome (BADAS)
• clinically Sweet’s like• erythema nodosum• papules, blisters, pustules on
trunk and proximal arms
Histopathology –• neutrophilic dermatosis:
Sweet’s-like, oedema
![Page 18: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/18.jpg)
Differential diagnosis:Squamous cell carcinoma
Any time there are neutrophil microabscesses & histologically tempted to diagnose SCCthink: Could this be reactive? Differential diagnosis of SCC with neutrophils:
• Keratoacanthoma• Infection• Pyoderma gangrenosum• Sweet’s & variants
![Page 19: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/19.jpg)
Differential diagnosis:
classical pyoderma gangrenosum:
typical “undermining” of surface by abscess
![Page 20: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/20.jpg)
Superficial granulomatous pyoderma gangrenosum
• Idiopathic, especially on trunk, chronic often• Ulcer with superficial abscess rimmed by granulomatous inflammation• Haemorrhage, foreign material in ulcer bed eg hair shafts, vegetable matter • Usually superficial but can extend more deeply• Pseudoepithleiomatous hyperplasia• Culture to exclude infection
![Page 21: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/21.jpg)
Role of biopsy in neutrophilic dermatoses
Biopsy useful –
• a) for histology
• b) culture to exclude infection
• But – need deep incisional biopsy or risk misinterpretation
![Page 22: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/22.jpg)
Neutrophil-rich dermatoses -infections
![Page 23: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/23.jpg)
Neutrophil-rich dermatoses -infections
Common
• abscesses
• cellulitis
• (necrotising fasciitis)
• mainly bacterial
• may require surgical incision, drainage and culture
• consider biopsy for histology if not responding to treatment
![Page 24: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/24.jpg)
Neutrophil-rich dermatoses -infections
• atypical mycobacteria
• fungal infection:– Superficial: on biopsy many lack neutrophils, neutrophil rich
intracorneal pustules in some
– Deep: similar histology to atypical mycobacterial infection
• Immunosuppression:– requires full panel of special stains,
– may require immunohistochemistry for viruses, culture, serology etc
• rarer infections – often neutrophil component
![Page 25: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/25.jpg)
Atypical mycobacterial infection
M.chelonae
Pseudoepitheliomatous hyperplasia of epidermis common
![Page 26: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/26.jpg)
Atypical mycobacterial infection:suppurative granulomatous inflammation i.e. collections of neutrophils as well as macrophages
![Page 27: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/27.jpg)
“hole” in the dermis: but not empty
![Page 28: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/28.jpg)
Ziehl-Neelsen: “holes” in the dermisfilled with acid fast bacilli M. chelonae – often see lots of mycobacteria unlike many otheratypical mycobacterial infections
![Page 29: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/29.jpg)
Cutaneous Atypical Mycobacterial Infection
Clinical features variable:
•Verrucous nodules•Erythematous nodules•Ulcer•Abscesses•Cellulitis•Rosacea-like lesions•panniculitis
![Page 30: Case 13 - University of Leeds](https://reader030.vdocuments.mx/reader030/viewer/2022012600/61976ebb4872d421b5097358/html5/thumbnails/30.jpg)
Case 13
Female 85. Recurrent urinary tract infections, and rash over fingers and dorsal thumb.
The best diagnosis is:
A. Pyodermatitis /Pyostomatitis vegetans
B. Neutrophilic dermatosis of the dorsal hands
C. Squamous cell carcinoma
D. Atypical mycobacterial infection (M.chelonae)