self assessment cases
TRANSCRIPT
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Self assessment courseSelf assessment course
Aleodor Andea, MD Aleodor Andea, MD
Associate Associate Professor of Pathology andProfessor of Pathology and Dermatology Dermatology Director of Director of Dermatopathology Dermatopathology
University of Alabama at BirminghamUniversity of Alabama at Birmingham
Birmingham,Birmingham, AL AL
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Cazul 1
� Un pacient de 42 de ani se prezinta cu un
nodul facial asimptomatic. A. Tricofoliculom
B. Tricoadenom
C. Tricoblastom
D. Tricoepiteliom
E.Ch
ist eruptiv cu par velos
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Cazul 1
� Un pacient de 42 de ani se prezinta cu un
nodul facial asimptomatic.A. Tricofoliculom
B. Tricoadenom
C. Tricoblastom
D. Tricoepiteliom
E.Ch
ist eruptiv cu par velos
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TrichofolliculomaTrichofolliculoma
�� Clinical:Clinical:
± ± Flesh colored papules with central pore with Flesh colored papules with central pore with
protruding hairsprotruding hairs
± ± Adults Adults
± ± Face,Face, scalp,neckscalp,neck
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Alte optiuni
� Tricoadenom
� Tricoepiteliom
� Tricoblastom
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TrichoadenomaTrichoadenoma
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TrichoepitheliomaTrichoepithelioma
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TrichoblastomaTrichoblastoma
�� Variant of trichoepitheliomaVariant of trichoepithelioma
�� Constituted largely of follicular Constituted largely of follicular
germinative cellsgerminative cells
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Vellus hair cyst� Multiple small (eruptive), papules on face, neck, chest, limbs,
axillae� young adults/ children
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Eruptive vellus hair cyst
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Cazul 2
� Un pacient se prezinta cu un nodul de
culoare rosiatica localizat la baza
incheieturii miini. A. Keratosa seboreica
B. Hidroacanthom
C. Spiradenom ecrin
D. Porom ecrin
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Cazul 2
� Un pacient se prezinta cu un nodul de
culoare rosiatica localizat la baza
incheieturii miini. A. Keratosa seboreica
B. Hidroacanthom
C. Spiradenom ecrin
D. Porom ecrin
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Eccrine PoromaEccrine Poroma
�� Clinical:Clinical:
± ± Adults Adults
± ± solitary, sessilesolitary, sessile ± ± skinskin--colored to red papule / nodulecolored to red papule / nodule
± ± sole or side of the foot; rare in other sitessole or side of the foot; rare in other sites
± ± up to 3cm in diameter up to 3cm in diameter
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Eccrine poroma
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Alte optiuni
� Hidroacantom
� Keratosa seboreica
� Spiradenom ecrin
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Hidroacanthoma SimplexHidroacanthoma Simplex
�� Clinical:Clinical:
± ± skin colored to red papule or plaqueskin colored to red papule or plaque
± ± trunk or extremitiestrunk or extremities
± ± elderlyelderly
± ± Often confused with SK, BCC, or SCC Often confused with SK, BCC, or SCC
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Hydroacanthoma simplex
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Seborr heic Keratosis
� Among the most
common benign
epidermal
proliferationsdeveloping in the
middle-aged and
elderly.
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Seborr heic Keratosis
� Hyperkeratosis,papillomatosis
� Pseudohorn cysts
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SpiradenomaSpiradenoma
�� Clinical:Clinical: ± ± 0.30.3--5.0 cm.5.0 cm.
± ± dermal painful noduledermal painful nodule ± ± blue colorationblue coloration
± ± young adultsyoung adults
± ± head, neck, upper trunk or upper extremitieshead, neck, upper trunk or upper extremities
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spiradenoma
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Cazul 3
� O femeie de 67 de ani se prezinta cu o
leziune pe picior de culoare rosiatica, in
relief, cu scuame prezenta de citeva luni. A. Pheohifomicoza
B. Necrobioza lipoidica
C. Xanthogranulom necrobiotic
D.C
romoblastomicozaE. Tinea nigra
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Cazul 3
� O femeie de 67 de ani se prezinta cu o
leziune pe picior de culoare rosiatica, in
relief, cu scuame prezenta de citeva luni. A. Pheohifomicoza
B. Necrobioza lipoidica
C. Xanthogranulom necrobiotic
D. Cromoblastomicoza
E. Tinea nigra
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Chromoblastomycosis
� Disease of tropics and subtropics
� Caused by saprophitic pigmented fungi
from plants debris and soil
� Organisms
± Fonseca pedrosoi (Phialospora pedrosoi)
± Phialospora compacta
± Phialospora verucossa
± Cladosporium carrionii
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Verrucous nodule or plaque
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Alte optiuni
� Pheohifomicoza
� Necrobioza lipoidica
� Xanthogranulom necrobiotic� Tinea nigra
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Mycoses� Superficial fillamentous
infections
± Dermatophytoses
� Yeast infections
± Candidosis
± Cryptococcosis
± Pityriasis versicolor
± Pityrosporum folliculitis
� Systemic mycoses
± Blastomycosis
± Coccidioidomycosis
± Paracoccidioidomycosi
± Histoplasmosis
� Dematiaceous fungi
± Chromomycosis
± Phaehyphomycosis
± Sporotrichosis
± Tinea nigra
� Zygomycoses
� Hyalohyphomycoses
± Fusariosis
± Penicilliosis
± Aspergilosis
� Algal infections
± Protothecosis
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Phehyphomycosis
� Verrucous, nodular or cystic lesions
� Organisms
± Exophiala jeanselmei
± Wangiella dermatidis
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Tinea nigra
� Exophiala werneckii
� Slowly enlarging brown to black macule
� Palms, plantar surface� Mimicks melanocytic lesions
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Necrobiotic xanthogranuloma
� Chronic disease
� Sharply demarcated nodules and plaques
� Violaceous to red� Periorbital area
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Cazul 4
� O femeie de 30 de ani se prezinta cu un
nodul intradermic dureros pe antebratul
sting. A. Neurofibrom
B. Neurilemom
C. Neurom
D. Leiomiom
E. Leiomiosarcom
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Cazul 4
� O femeie de 30 de ani se prezinta cu un
nodul intradermic dureros pe antebratul
sting. A. Neurofibrom
B. Neurilemom
C. Neurom
D. Leiomiom
E. Leiomiosarcom
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SCHWANNOMA
(neurilemmoma)� Clinical:
± single, sporadic tumors;
± 20-50 yrs;
± M=F;
± head, neck, limbs (i.e. usually named nerves)
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SCHWANNOMA
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CM
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S-100
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Alte optiuni
� Neurofibrom
� Neurom
�Leiomiom
� Leiomiosarcom
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� PERIPHERAL NERVE SHEATH TUMORS ± Neuroma
± Palisaded encapsulated neuroma
± Neurofibroma
± Schwannoma ± Granular cell tumor
NEUROMA
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NEUROMA
(traumatic neuroma)� Clinical:
± history of injury
± nerve severing event
± a firm, painful nodule
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TRAUMATIC NEUROMA
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NEUROFIBROMA
� Clinical:
± 90% are solitary, not associated with NF;
± diffuse & plexiform closely associated with NF-1
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Neurofibroma vs. Schwannoma
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NEUROFIBROMA
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NEUROFIBROMA
PLEXIFORM
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PLEXIFORM
NEUROFIBROMA
PLEXIFORM
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PLEXIFORM
NEUROFIBROMA
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Cazul 5
� O femeie de 40 de ani se prezinta cu o
placa dureroasa, eritematoasa si indurata
in zona posterioara a gambei. A. Eritem nodos
B. Erithem indurat
C. Necroza grasa diseminata (Paniculita
pancreatica)
D. Deficienta de alfa-1-antitripsina
E. Paniculita lipomembranoasa
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Cazul 5
� O femeie de 40 de ani se prezinta cu o
placa dureroasa, eritematoasa si indurata
in zona posterioara a gambei.A. Eritem nodos
B. Erithem indurat
C. Necroza grasa diseminata (Paniculita
pancreatica)
D. Deficienta de alfa-1-antitripsina
E. Paniculita lipomembranoasa
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Erythema nodosum
� Septal panniculitis
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Erythema Nodosum
acute painful nodules, anterior lower legs
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Classification of panniculitis
� Septal
� Lobular
S t l
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Septal
� Erythema Nodosum� Subcutaneous morphea/scleroderma
� Necrobiosis Lipoidica
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Lobular
� Erythema Induratum
� Pancreatic Panniculitis
� Alpha 1 anti-trypsin deficiency
� Lupus panniculitis
� Subcutaneous panniculitis-like T cellLymphoma
� Subcutaneous fat necrosis of the newborn &Sclerema neonatorum
� Lipodermatosclerosis
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Alte optiuni
� Erithem indurat
� Paniculita pancreatica
� Deficienta de alfa-1-antitripsina� Paniculita lipomembranoasa
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Alpha-1-antitrypsin deficiency
� Tender nodules on
trunk or extremities,
� Precipitated by
trauma
� Ulceration and oily
discharge.
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Erythema induratum
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Tender nodules on calves
y
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Lipomembraneous Panniculitis or
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Lipomembraneous Panniculitis or
Membranous Lipodystrophy� Venous insufficiency: =Lipodermatosclerosis.
� End result of multiple disease processes:
± EN, Morphea profunda, Lupus, traumatic fat necrosis,insulin lipoatrophy, encapsulated fat necrosis,dermatomyosistis and Bechet¶s disease.
Lipodermatosclerosis
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Lipodermatosclerosis
�indurated inverted
champagne bottleappearance
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Pancreatic panniculitis
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� Painful subcutaneousnodules / plaques
� Thighs, buttocks,
lower trunk & distal
extremities.
� Acute pancreatitis
� Acinic cell pancreatic
carcinoma� Etiology: fat digestion
by of pancreatic
enzymes
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C l 6
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Cazul 6
� O femeie de 31 de ani se prezinta cu un
nodul polipoid de 3 cm crescut pe o
leziune in placa indurata pe partea
superioara a spatelui. A. Neurilemom
B. Dermatofibrom
C. Dermatofibrosarcom protuberant
D. Fibroxantom atipic
C l 6
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Cazul 6
� O femeie de 31 de ani se prezinta cu un
nodul polipoid de 3 cm crescut pe o
leziune in placa indurata pe partea
superioara a spatelui. A. Neurilemom
B. Dermatofibrom
C. Dermatofibrosarcom protuberant
D. Fibroxantom atipic
DFSPDFSP
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DFSPDFSP
�� FibrohistiocyticFibrohistiocytic tumor tumor
�� Intermediate malignant potential:Intermediate malignant potential:
± ± locally aggressive (11locally aggressive (11--73% local recurrence)73% local recurrence)
± ± but a low rate of metastasis (1but a low rate of metastasis (1--3%) to lung.3%) to lung.
FIBROHISTIOCYTIC TUMORSFIBROHISTIOCYTIC TUMORS
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FIBROHISTIOCYTIC TUMORSFIBROHISTIOCYTIC TUMORS
�� BenignBenign ± ± DermatofibromaDermatofibroma
�� IntermediateIntermediate
± ± Atypical Atypical fibroxanthomafibroxanthoma
± ± DermatofibrosaromaDermatofibrosaroma protuberansprotuberans
�� MalignantMalignant
± ± Malignant fibrousMalignant fibrous histiocytomahistiocytoma
Enlarging plaque, sometime with a nodule.Enlarging plaque, sometime with a nodule.
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Alte optiuni
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Alte optiuni
� Neurilemom
� Dermatofibrom
� Fibroxantom atipic
� Histiocitom fibros malign
DERMATOFIBROMADERMATOFIBROMA
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DERMATOFIBROMADERMATOFIBROMA
�� Clinical:Clinical:
± ± 0.50.5 ± ± 1 cm1 cm
± ± LegLeg
± ± puckers when pinc
hedpuckers w
hen pinc
hed
± ± may be pigmented (due to melanin or hemorr hage)may be pigmented (due to melanin or hemorr hage)
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Cazul 7
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Cazul 7
� Un barbat de 30 de ani a remarcat aparitia
recenta a unui nodul rosu-purpuriu de
bratul drept. Biopsia confirma un
diagnostic de: A. Hemangiom capilar
B. Angiokeratom
C. Sarcom Kaposi
D. Nev intradermic
E. Carcinom cu celule squamouase, tip cu celule
fusiforme
Cazul 7
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Cazul 7
� Un barbat de 30 de ani a remarcat aparitia
recenta a unui nodul rosu-purpuriu de
bratul drept. Biopsia confirma un
diagnostic de: A. Hemangiom capilar
B. Angiokeratom
C. Sarcom Kaposi
D. Nev intradermic
E. Carcinom cu celule squamouase, tip cu celule
fusiforme
Kaposi Sarcoma
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� Low-grade clonal endothelial proliferation� Variants:
± Classic KS:
� Elderly patients
� Distal extremities
± African KS
� Likely related to chronic immunosuppression
± AIDS-related/ immunosuppression:
� Disseminate multi-organ disease, predilection for mucocutaneous sites, aggressive course
Kaposi Sarcoma
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PAS
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PAS
CD 31 CD 34
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HHV8
Alte optiuni
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Alte optiuni
� Hemangiom capilar
� Angiokeratom
� Nev intradermic
� C arcinom cu celule squamouase, tip cu
celule fusiforme
Lobular capillary hemangioma
(Pyogenic granuloma)
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(Pyogenic granuloma)
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Angiokeratoma
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Intradermal nevus
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Intradermal nevus
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Cazul 8
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Ca u 8
� O femeie de 60 de ani se prezinta cu
leziuni eritematoase dureroase pe frunte.
Biopsia confirma un diagnostic de:
A. Foliculita bacterianaB. Zona zoster
C. Lupus eritematos bulos
D. Reactie la intepatura de insecta
E. Pemfigus vulgar
Cazul 8
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� O femeie de 60 de ani se prezinta cu
leziuni eritematoase dureroase pe frunte.
Biopsia confirma un diagnostic de:
A. Foliculita bacterianaB. Zona zoster
C. Lupus eritematos bulos
D. Reactie la intepatura de insecta
E. Pemfigus vulgar
Zona Zoster
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� Clinical:
± epidemic, acute vesicular eruption with a
febrile illness
± rash develops in successive stages ± pneumonia in immunocompromised
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Alte optiuni
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p
� Foliculita bacteriana
� Lupus eritematos bulos
� Reactie la intepatura de insecta
� P emfigus vulgar
Staphyloccal folliculitis
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Bullous lupus
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Insect bite
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Insect bite
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Case 9
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� Care este cel mai probabil diagnostic
bazat pe examenul histopatologic? A. Carcinoma bazocelular
B. TricoblastomC. Porom ecrin
D. Carcinom cu celule Merkel
E. Limfom cutanat cu celule B mari, difuz
Case 9
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� Care este cel mai probabil diagnostic
bazat pe examenul histopatologic? A. Carcinoma bazocelular
B. TricoblastomC. Porom ecrin
D. Carcinom cu celule Merkel
E. Limfom cutanat cu celule B mari, difuz
Merkel cell carcinoma
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� First reported by Toker in 1972
� Merkel cell origin is not clearly
demonstrated
� Neuroendocrine tumor of the skin
� Clinical:
± Sun-exposed areas of elderly patients
± Nodules 2 cm average diameter
�3 cm ulcerated and crusted nodule
�Clinical Dx: BCC, Amelanotic MM, Metastatic cancer
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CK 20 Chromogranin
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Synaptophysin
Alte optiuni
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� Carcinoma bazocelular
� T ricoblastom
� P orom ecrin
� Limfom cutanat cu celule B mari, difuz
Basal Cell Carcinoma
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� Most common cutaneous malignant tumor (70%)
� Head and neck areas
� Males
� Age related
Microscopic
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� Basaloid cells with peripheral palisading
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Primary cutaneous diffuse large B-
cell lymphoma, leg type
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cell lymphoma, leg type
� Definition: is a primary cutaneous large
cell lymphoma with confluent sheets of
centroblasts and immunoblasts wh
ich occurs on the legs
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Willemze et al. 2005 105:3768-85
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Case 10
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� Care este cel mai probabil diagnosticbazat pe examenul histopatologic?
A. Porfirie cutanata tardiva
B. Eritem multiformC. Pemfigoid bulos
D. Pemfigus vulgar
E. Lupus eritematos bulos
Case 10
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� Care este cel mai probabil diagnosticbazat pe examenul histopatologic?
A. Porfirie cutanata tardiva
B. Eritem multiformC. Pemfigoid bulos
D. Pemfigus vulgar
E. Lupus eritematos bulos
Porphyria cutanea tarda
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� Blisters develop
in sun-exposed
areas� Dorsum of the
hands
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Alte optiuni
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� E ritem multiform
� Pemfigoid bulos
� P emfigus vulgar
� Lupus eritematos bulos
Bullous PemphigoidBullous Pemphigoid
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�� Most commonMost common subepidermalsubepidermal blisteringblisteringdisease.disease.
�� Abdomen, groin, flexor surface of arms and Abdomen, groin, flexor surface of arms and
legslegs
�� ElderlyElderly
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Case 11
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� Cel mai probabil diagnostic bazat exclusivpe examenul histopatologic este:
A. Scleromixedem
B. Fasciita nodularaC. Morfea profunda
D. Fibroxantom atipic
E. Histiocitom fibros malign
Case 11
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� Cel mai probabil diagnostic bazat exclusivpe examenul histopatologic este:
A. Scleromixedem
B. Fasciita nodularaC. Morfea profunda
D. Fibroxantom atipic
E. Histiocitom fibros malign
Nodular FasciitisNodular Fasciitis
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�� Upper extremities, trunkUpper extremities, trunk
�� Rapid growthRapid growth
�� Easily confused with a sarcomaEasily confused with a sarcoma
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Alte optiuni
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� Scleromixedem
� Morfea profunda
� Fibroxantom atipic
� Histiocitom fibros malign
Scleromyxedema
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± M-protein Paraproteinemia (85%): IgG
± Onset: Middle aged adults
Scleromyxedema
± Papules plaques &
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Papules, plaques &
infiltrative lesions
± Face; Neck upper
Arms, legs.
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Deep morphea
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Case 12
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� Cel mai probabil diagnostic bazat exclusivpe examenul histopatologic este:
A. Lichen plan
B. Lichen striat
C. Lichen nitidus
D. Lichen planopilar
Case 12
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� Cel mai probabil diagnostic bazat exclusivpe examenul histopatologic este:
A. Lichen plan
B. Lichen striat
C. Lichen nitidus
D. Lichen planopilar
Lichen Planus
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� Papules
� Pruritic
� Poligonal
� Purple
� Flexor surface or
wrists, trunk, thighs,
genitalia
Band-like infiltrateEpidermal acanthosis
Compact Hyperkeratosis
Wedge-shaped hypergranulosis
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Saw-tooth rete
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Vacuolar -interface changes = liquefactive
degeneration
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Subepidermal clefting ±Caspary-JosephSpace
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Dyskeratotic cells = Civatte bodiesMelanophages
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Colloid bodies
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Fibrin IgM
Direct immunofluorescence
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Case 13
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� Care este cel mai probabil diagnosticbazat pe examenul histopatologic?
A. Lichen plan
B. Lichen striat
C. Lichen nitidus
D. Lichen planopilar
Case 13
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� Care este cel mai probabil diagnosticbazat pe examenul histopatologic?
A. Lichen plan
B. Lichen striat
C. Lichen nitidus
D. Lichen planopilar
LichenLichen StriatusStriatus
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�� Unknown etiologyUnknown etiology�� Linear Linear papular papular
eruption along oneeruption along one
side of body, usuallyside of body, usuallythe length of anthe length of an
extremityextremity
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Lichenoid infiltrate on 3-4 dermal papillae
Less dense than in LP
Acanthosis
Spongiosis with exocytosis of lymphocytes
Hyperorthokeratosis and focal parakeratosis
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Vacuolar interface changesDyskeratotic cells at all levels
Spongiosis with exocytosis of lymphocytes
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Alte optiuni
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� Lichen nitidus� Lichen planopilar
Lichen Nitidus
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� Multiple small flesh colored papules
� 1-2 mm
� Upper extremities,chest, abdomen,
genitalia
� Children and youngadults
Claw-like rete (ball and claw)Lichenoid infiltrate
Thinned epidermis with dyskeratosis and vacuolar changes
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Granulomatous infiltrate
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Perieccrine infiltrate
LichenLichen PlanopilarisPlanopilaris
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�� A common cause of scarring alopecia A common cause of scarring alopecia�� Keratotic follicular lesions and erythema atKeratotic follicular lesions and erythema at
marginsmargins
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Case 14
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� Cel mai probabil diagnostic bazat exclusivpe examenul histopatologis este:
A. Lupus eritematos cronic cutanat (discoid)
B. Lichen plan
C. Keratoza lichenoida
D. Eritem multiform
Case 14
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� Cel mai probabil diagnostic bazat exclusivpe examenul histopatologis este:
A. Lupus eritematos cronic cutanat (discoid)
B. Lichen plan
C. Keratoza lichenoida
D. Eritem multiform
Erythema multiforme
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� Pleomorphic eruption� Individual lesions: papule -> vesicle-
>target
� Herpes, drugs, mycoplasma� Minor/ major forms (Stevens-Johnson)
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Erythema multiforme/Stevens-Johnson
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Alte optiuni
Li h l
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� Lichen plan� Lupus eritematos cronic cutanat (discoid)
� Keratoza lichenoida
Lichen Planus-Like Keratosis� Solitary, 3-10 mm
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� Scaly, violaceous or
pink
� Arms and chest
� Middle age and
elderly women
� DDX: BCC, SCCIS
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Case 15
C l i b bil di ti hi t l i t
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� Cel mai probabil diagnostic histologic este: A. Psoriasis
B. Lichen simplex cronicus
C. Lichen sclerotic si atrofic
D. Morfea
E. Fasciita eosinofilica
Case 15
Cel mai probabil diagnostic histologic este:
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� Cel mai probabil diagnostic histologic este: A. Psoriasis
B. Lichen simplex cronicus
C. Lichen sclerotic si atrofic
D. Morfea
E. Fasciita eosinofilica
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Alte optiuni
� Psoriasis
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� P soriasis� Lichen simplex cronicus
� Morfea
� Fasciita eosinofilica
Lichen simplex chronicus
� Scaly thickened
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� Scaly t ickenedplaques develop in
response to persistent
rubbing
� Predilection for: ± Nape of neck
± Ulnar border of forearms
± Wrists
± Pretibial region
± Dorsa of feet
± Perianal and genital
region
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Eosinophilic Fasciitis (Shulman¶s
Syndrome)
� Sudden onset
� 50% occur after strenuous activity
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� 50% occur after strenuous activity.
� Symmetric induration of skin of limbs > trunk
� Characteristic orange-peel appearance.Spares hands.
� Peripheral eosinophilia.
� Malaise, weakness, fever and weight loss
OrangeOrange--peelpeel
appearanceappearance
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Layering effect of Layering effect of hyalinizedhyalinized sclerotic collagensclerotic collagenalternating with trapped fat and inflammatoryalternating with trapped fat and inflammatorycells.cells.
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Case 16
� Cel mai probabil diagnostic bazat exclusiv
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� Cel mai probabil diagnostic bazat exclusivpe examenul histopatologis este:
A. Dermatita spongiotica
B. Psoriasis
C. Pitiriasis rubra pilaris
D. Micoza fungoida
Case 16
� Cel mai probabil diagnostic bazat exclusiv
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Cel mai probabil diagnostic bazat exclusivpe examenul histopatologis este:
A. Dermatita spongiotica
B. Psoriasis
C. Pitiriasis rubra pilaris
D. Micoza fungoida
Psoriasis
� Well-circumscribed
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Well circumscribederythematous
patches with a
silvery scale
� Extensor surfaces
of the extremities,
sacral region,
scalp, nails
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Cazul 17
� Care este cel mai probabil diagnosticb t l hi t t l i ?
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Care este cel mai probabil diagnosticbazat pe examenul histopatologic?
A. Dermatita spongiotica
B. Psoriasis
C. Pitiriasis rubra pilaris
D. Micoza fungoida
Cazul 17
� Care este cel mai probabil diagnosticb t l hi t t l i ?
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Care este cel mai probabil diagnosticbazat pe examenul histopatologic?
A. Dermatita spongiotica
B. Psoriasis
C. Pitiriasis rubra pilaris
D. Micoza fungoida
Mycosis fungoides
� Small to medium sized T lymphocytes withb if l i
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Small to medium sized T lymphocytes with cerebriform nuclei
� Older adults
� Indolent clinical course ± Patch
± Plaque
± Tumor
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Pautrier microabscesses
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CD
3 + CD
4 +
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CD
8
-
CD
7-
Alte optiuni
± Dermatita spongioticaPsoriasis
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± P soriasis
± Pitiriasis rubra pilaris
Spongiotic dermatitis
� Allergic contact dermatitis� Dyshidrotic eczema
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g� Dyshidrotic eczema
� Nummular dermatitis
� Atopic dermatitis� Seborr heic dermatitis
� Phototoxic dermatitis
� Pityriasis rosea
� Stasis dermatitis
Almost identical histology
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Pityriasis rubra pilaris
� Small follicular papules with a central plugP if lli l th
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g� Perifollicular erythema
� Islands of sparing
� Palmoplantar keratoderma
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Cazul 18
� Cel mai probabil diagnostic bazat exclusivpe examenul histopatologic este:
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pe examenul histopatologic este: A. Psoriasis
B. Pitiriasis rubra pilar
C. Dermatita spongiotica
D. Scabie
E. Micoza fungoida
Cazul 18
� Cel mai probabil diagnostic bazat exclusivpe examenul histopatologic este:
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pe examenul histopatologic este: A. Psoriasis
B. Pitiriasis rubra pilar
C. Dermatita spongiotica
D. Scabie
E. Micoza fungoida
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Cazul 19
� Alegeti cel mai probabil diagnostic dinoptiunile de mai jos, bazat pe examenul
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optiunile de mai jos, bazat pe examenul
histopatologic. A. Pemfigoid bulos
B. Pustuloz exantematic acut generalizat
C. Pemfigus vulgar
D. Boala IgA lineara
E. Pseudoporfirie
Cazul 19
� Alegeti cel mai probabil diagnostic dinoptiunile de mai jos, bazat pe examenul
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optiunile de mai jos, bazat pe examenul
histopatologic. A. Pemfigoid bulos
B. Pustuloz exantematic acut generalizat
C. Pemfigus vulgar
D. Boala IgA liniara
E. Pseudoporfirie
Linear IgA Bullous DermatosisLinear IgA Bullous Dermatosis
��Ch
ronic Bullous Disease of Ch
ildhood:
Chronic Bullous Disease of
Childhood: ± ± Large, tense bullae arising during the 1Large, tense bullae arising during the 1stst decadedecade
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± ± Predilection for perioral and genital regionsPredilection for perioral and genital regions
± ± Usually benign courseUsually benign course
�� Adult linear IgA Bullous Dermatosis Adult linear IgA Bullous Dermatosis ± ± Varied presentations, sometimes annular with lesionsVaried presentations, sometimes annular with lesions
usually involving trunk and limbsusually involving trunk and limbs
± ± Common association with drug Rx (vancomycin)Common association with drug Rx (vancomycin)
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Chronic BullousChronic Bullous DermatosisDermatosis of Childhoodof Childhood
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IgA
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SubepidermalSubepidermal BlistersBlisters
�� Cell Poor Cell Poor ::
± ± EB, EBA, PCTEB, EBA, PCT
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�� Cell Rich:Cell Rich:
± ± Lymphocytes:Lymphocytes: EM, Fixed drugEM, Fixed drug
± ± Neutrophils:Neutrophils: DH,DH, Linear IgALinear IgA,, BullousBullous SLESLE
± ± EosinophilsEosinophils:: BP, HG, IP, arthropod, drugBP, HG, IP, arthropod, drug
± ± Mast Cells:Mast Cells: BullousBullous MastocytosisMastocytosis
Alte optiuni
�P
emfigoid bulos� Pustuloz exantematic acut
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Pustuloz exantematic acut
generalizat
�P
emfigus vulgar � P seudoporfirie
Acute generalizedexanthematous pustulosis
� Sterile, miliary
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pustules on an
erythematous
background� Fever, blood
leukocytosis
� Occurs within hoursafter ingestion of
drugs
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DDX of subcorneal pustules
± ± BullousBullous impetigoimpetigo
± ± StaphylococcalStaphylococcalscalded skinscalded skin
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± ± PemphigusPemphigus foliaceusfoliaceus
± ± IgAIgA PemphigusPemphigus
± ± Acute generalized Acute generalized
exanthematousexanthematous
pustulosispustulosis
± ± Pustular Pustular psoriasispsoriasis ± ± SubcornealSubcorneal pustular pustular
dermatosisdermatosis
Cazul 20
� Alegeti cel mai probabil diagnostic bazatpe examenul histopatologic din optiunile
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de mai jos. A. Pemphigoid bulos
B. Lupus eritematos bulos
C. Pemfigus vulgar
D. Boala Hailey-Hailey
E. Pseudoporfirie
Cazul 20
� Alegeti cel mai probabil diagnostic bazatpe examenul histopatologic din optiunile
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de mai jos. A. Pemphigoid bulos
B. Lupus eritematos bulos
C. Pemfigus vulgar
D. Boala Hailey-Hailey
E. Pseudoporfirie
Pemphigus vulgaris
� 80% of pemphigus
cases� Oral blisters then
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cutaneous lesions
� Flacid blisters onnormal base
� Trunk, groin, axillae,
scalp, face, presure
points
Pemphigus VulgarisPemphigus Vulgaris
�� Ab Ab directed againstdirected against desmogleindesmoglein 33�� About half of patients also haveAbout half of patients also have AbAb toto
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About half of patients also have About half of patients also have Ab Ab toto
desmogleindesmoglein 11
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DIF
� IgG in the intercellular
regions of theepidermis lesional
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epidermis, lesional
and perilesional
Suprabasilar Blisters
� Pemphigus Vulgaris� Paraneoplastic Pemphigus
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� Paraneoplastic Pemphigus
� Acantholytic dyskeratosis
± Hailey-Hailey Disease
± Darier¶s Disease
± Grover¶s Disease
Alte optiuni
A. P emphigoid bulos
B. Lupus eritematos bulos
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C. Boala Hailey-Hailey
D. P seudoporfirie
Hailey-Hailey disease
� Familial benign chronic pemp
higus
� Genodermatosis, AD
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� Onset in teens
� ATP2C1 (calcium pump)
Hailey Hailey Disease
Axillary Axillary skin showingskin showing
erythematouserythematous eroded anderoded andcrusted lesionscrusted lesions
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c us ed es o sc us ed es o s
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�� PartialPartial acantholyisacantholyis
(dilapidated brick wall)(dilapidated brick wall)
�� AcantholyticAcantholytic cellscells
�� No follicular involvement No follicular involvement
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Cazul 21
� Alegeti cel mai probabil diagnostic bazatpe examenul histopatologic din optiunile
d i j
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de mai jos. A. Granulom anular
B. Necrobioza lipoidicaC. Nodul reumatic
D. Infectie cu micobacteria
E. Sarcoidoza
Cazul 21
� Alegeti cel mai probabil diagnostic bazatpe examenul histopatologic din optiunile
de mai jos
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de mai jos. A. Granulom anular
B. Necrobioza lipoidicaC. Nodul reumatic
D. Infectie cu micobacteria
E. Sarcoidoza
Sarcoid- Clinical Features
� Blacks > Wh
ites� Women > Men
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� Cutaneous lesions in <25% of patients
with systemic disease
� If confined to skin, runs an indolent course
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Asteroid body
Cazul 22
�C
el mai probabil diagnostic bazat exclusivpe examenul histopatologic este:A Granulom anular
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A. Granulom anular
B. Necrobioza lipoidica
C. Nodul reumaticD. Infectie cu micobacteria
E. Sarcoidoza
Cazul 22
� Cel mai probabil diagnostic bazat exclusiv
pe examenul histopatologic este:A Granulom anular
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A. Granulom anular
B. Necrobioza lipoidica
C. Nodul reumaticD. Infectie cu micobacteria
E. Sarcoidoza
Granuloma Annulare
� Papules
� Annular or
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arciform plaques.
� Commonly onextremities.
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Cazul 23
� Alegeti cel mai probabil diagnostic din
optiunile de mai jos, bazat pe examenul
histopatologic:
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histopatologic: A. Granulom anular
B. Necrobioza lipoidicaC. Nodul reumatic
D. Infectie cu micobacteria
E. Sarcoidoza
Cazul 23
� Alegeti cel mai probabil diagnostic din
optiunile de mai jos, bazat pe examenul
histopatologic:
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histopatologic: A. Granulom anular
B. Necrobioza lipoidicaC. Nodul reumatic
D. Infectie cu micobacteria
E. Sarcoidoza
Rheumatoid Nodules
� Subcutaneous nodules, usually in the
vicinity of joints.
� Can persist for years
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� Can persist for years
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Alte optiuni
� Granulom anular
� Necrobioza lipoidica
Infectie cu micobacteria
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� Infectie cu micobacteria
� Sarcoidoza
Necrobiosis Lipoidica
� Predilection for legs
(shins), usually bilateral.
� Red papules, enlarging to
become plaques which
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become plaques which
develop atrophic,
depressed centers
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Mycobacterial infection
� Less discrete than sarcoidal granulomas
with tendency toward confluence
� More giant cells and often accompanied
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More giant cells and often accompanied
by a rim of lymphocytes and plasma cells
� Caseous necrosis sometimes
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Cazul 24
� Cel mai probabil diagnostic in acest caz
este: A. Vasculita leucocitoclazica
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B. Angiodermita purpurica si pigmentara
C. Purpura actinicaD. Coagulare intravasculara diseminata
Cazul 24
� Cel mai probabil diagnostic in acest caz
este:A. Vasculita leucocitoclazica
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B. Angiodermita purpurica si pigmentara
C. Purpura actinicaD. Coagulare intravasculara diseminata
Leukocytoclastic vasculitis
� Most common vasculitis
� Not a disease but a manifestation of
circulating IC caused by an underlying
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c cu a g C caused by a u de y g
disorder
Causes of allergic vascultitis
� Infection: bacteria, mycobacteria, viral
� Drugs: phenacetin, sulfonamies, penicilin,iodides
� Chemicals: insecticides
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� Associated diseases:
± SLE, other CTD ± Lymphoma, carcinoma
± RA
± Sjogren sd
± HS purpura
± Cryoglobulinemia
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Alte optiuni
� Angiodermita purpurica si pigmentara
� Purpura actinica
� Coagulare intravasculara diseminata
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Coagulare intravasculara diseminata
Pigmented purpuric dermatosis
� Group of purpuric
diseases
� Variable
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pigmentation
� Lower extremities
� Young adults
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Solar purpura
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DIC/purpura fulminans
� Fibrin, platelets or mixed thrombi in the
capillaries and venules
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Cazul 25
� Un pacient de 80 de ani se prezinta cu un
nodul verucos pe fata si o biopsie este
efectuata. Care este pasul urmator in
tratament?
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tratament?
A. Revine pentru control din 6 in 6 luni.B. Programat pentru excizie cu margini largi de
siguranta (1-2 cm)
C. Programat pentru excizie conservative a leziunii
D. Revine pentru control din 3 in 3 luni
Cazul 25
� Un pacient de 80 de ani se prezinta cu un
nodul verucos pe fata si o biopsie este
efectuata. Care este pasul urmator in
tratament?
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tratament?
A. Revine pentru control din 6 in 6 luni.B. Programat pentru excizie cu margini largi de
siguranta (1-2 cm)
C. Programat pentru excizie conservative a leziunii
D. Revine pentru control din 3 in 3 luni
Nevoid melanoma
� Variant of melanoma that is easily
mistaken for a common nevus
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Nevoid melanoma
� Definition from McKee: ³A melanoma that
a pathologist diagnosed as nevus and
wished that she/he had not´
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� Borderline histology but not borderline
prognosis!
Nevoid melanoma
� Wide age range
� No gender predilection
� Two types
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± Verrucous
± Dome shaped
� Clinical:
± Verrucous ±resemble a verruca or SK, if
pigmented a warty nevus
± Dome shaped -more non-specific
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Histology ±confusing features
� Dome shaped or
verrucous� Small size
� Symmetric of slightly
asymmetric
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asymmetric
� Circumscribed� Limited intraepidermal
component
� Pseudomaturation
Histology -clues
� Confluent or sheetlike
growth pattern
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Histology -clues
� Multiple mitotic figures
� Mitoses at the base of the lesion
� Atypical mitoses
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� Cytologic atypia
Size
Symmetry
Circumscription
Confluent growth at DEJ
NEVI MELANOMA
Small Large
Symmetric Asymmetric
Well-circumscribed Poorly-circumscribed
No Present
Histologic features
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Pagetoid spread
Maturation
Dermal pattern
Cytologic atypia
Mitoses in dermis
Atypical mitoses
Nested Sheetlike
No Prominent
Present Absent
Absent Severe
Absent
AbsentPresentPresent
Size
Symmetry
Circumscription
Confluent growth at DEJ
NEVINEVOID
MELANOMASmall Small
Symmetric Symmetric
Well-circumscribed Well-circumscribed
No No
Histologic features
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Pagetoid spread
Maturation
Dermal pattern
Cytologic atypia
Mitoses in dermis
Atypical mitoses
Nested Sheetlike
No No
Present Present
Absent Mild
Absent
AbsentPresentPresent
Cazul 26
� Aceasta leziune este negativa pentru
coloratiile imunohistochimice S100,keratina, p63 si desmina si pozitiva pentru
CD10 Care este diagnosicul cel mai
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CD10. Care este diagnosicul cel mai
probabil? A. Melanom desmoplastic
B. Leiomiosarcom
C. Carcinom squamocelular cu celule fuziforme
D. Fibroxantom atipic
E. Histiocitom fibros malign
Cazul 26
� Aceasta leziune este negativa pentru
coloratiile imunohistochimice S100,keratina, p63 si desmina si pozitiva pentru
CD10 Care este diagnosicul cel mai
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CD10. Care este diagnosicul cel mai
probabil? A. Melanom desmoplastic
B. Leiomiosarcom
C. Carcinom squamocelular cu celule fuziforme
D. Fibroxantom atipic
E. Histiocitom fibros malign
ATYPIC AL FIBROXANTHOMA ATYPIC AL FIBROXANTHOMA
�� Def: identical toDef: identical to pleomorphicpleomorphic malignant fibrousmalignant fibrous
histiocytomahistiocytoma (i.e. undifferentiated(i.e. undifferentiated pleomorphicpleomorphicsarcoma)sarcoma)
�� Clinical: nodule on sunClinical: nodule on sun--exposed head/neckexposed head/neck
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Leziuni dermice pleomorfice cucelule fusiforme
� Histiocitom fibros malign
� Fibroxantom atipic
� Carcinom squamocelular cu celule
fuziforme
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fuziforme
� Melanom desmoplastic
� Leiomiosarcom
Maligant fibrous histiocytoma
� Aceasi histologie cu fibroxantomul atipic
� Tumora este centrata in tesutul subcutanat
sau muschi
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� Prognosticul este foarte diferit:
± AFX -100% supravietuire la 5 ani
± MFH - ~20% supravietuire la 5 ani
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Spindle cell SCC
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Keratin (CK 903)
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Desmoplastic melanoma
� Predilection for elderly males
� Sun-damaged areas� 4% of invasive melanomas
� Infiltrated plaque or amelanotic nevus
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p q
� Often unsuspected clinically
± Spindle cells dispersed
into a dense stroma
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± Nodular lymphoid
infiltrates
± Associated MIS lentigo
maligna type (only about
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g yp ( y
half of cases) Carlson J. C ancer
1995: 76:478-94
± Oval to fusiform nuclei
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± Perineural invasion
± Deep infiltration into
dermis and subcutis
± Mitoses (sometimes
scant)
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Variable pleomorphism
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S100 Mart-1
HMB45
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HMB45
LeiomyosarcomaLeiomyosarcoma
�� CutaneousCutaneous leiomyosarcomaleiomyosarcoma
�� DeepDeep leiomyosarcomaleiomyosarcoma
�� Prognosis depends on locationPrognosis depends on location±± Dermal: benignDermal: benign
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Dermal: benignDermal: benign
± ± Deeper: more aggressiveDeeper: more aggressive
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Desmin
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Cazul 27
� Alegeti cel mai probabil diagnostic din
optiunile de mai jos, bazat pe examenulhistopatologic:
A. Cicatrice
B Ci t i hi t fi
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B. Cicatrice hipertrofica
C. Dermatofibrom
D. Morfea
E. Keloid
Cazul 27
� Alegeti cel mai probabil diagnostic din
optiunile de mai jos, bazat pe examenulhistopatologic:
A. Cicatrice
B Cicatrice hipertrofica
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B. Cicatrice hipertrofica
C. Dermatofibrom
D. Morfea
E. Keloid
Morphea
� trunk or extremities
� ivory plaque with violaceous border.
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Linear Scleroderma:Linear Scleroderma:
FrontalparietalFrontalparietal involvementinvolvementcalled Coup de Sabrecalled Coup de Sabre
Systemic SclerodermaMulti-system disorder affecting the
subcutaneous tissue, internal organs
and walls of blood vessels.
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Scleroderma/morphea Histololgy
Early
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Scleroderma/morphea
Histology Late
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Alte optiuni
� Cicatrice
� Cicatrice hipertrofica
� Keloid
� Dermatofibrom
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Hypertrophic Scars and Keloids
� Exuberant wound healing that either
± remains within the boundaries of original wound =hypetrophic scar
± extends outside the site of injury = keloid.
� More common in blacks
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Scar
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Cazul 28
� Cel mai probabil diagnostic in acest caz
este: A. Lupus eritematos bulos
B. Lupus eritematos cronic cutanat (discoid)
C. Lupus eritematos cutanat subacut
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D. Lupus eritematos tumid
E. Dermatomiozita
Cazul 28
� Cel mai probabil diagnostic in acest caz
este: A. Lupus eritematos bulos
B. Lupus eritematos cronic cutanat (discoid)
C. Lupus eritematos cutanat subacut
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D. Lupus eritematos tumid
E. Dermatomiozita
Discoid lupus erythematosus
� Female preponderance
� Sharply demarcated, erythematous scalypatches
� Follicular plugging
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� Face, neck, scalp, eyelids, lips, oralmucosa, hands
� Atrophy and scaling
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Lupus ErythematosusHistology
� Vacuolar interface dermatitis
� Superficial and deep perivascular andperiadnexal dermatitis
� Increased dermal mucin
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Direct immunofluorescence
� IgG, IgM, IgA, C3,
fibrin� 50%-90% positivity in
involved skin
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� Less positivity on thechest
Alte optiuni
Lupus eritematos bulos
Lupus eritematos cutanat subacut
Lupus eritematos tumid
Dermatomiozita
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Subacute cutaneous lupuserythematosus� Annular or
papulosquamous lesions
� Photosensitive areas: face,
neck, upper trunk, extensor
surface of arms
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� Non-scarring lesions
� May be associated with
drug ingestion
� In annular formh
isto differs only in degreefrom DLE
± More basal vacuolar changes
± More Chivatte bodies
± More epidermal atrophy
± More superficial dermal edema
± More superficial dermal mucin
L h k t i
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± Less hyperkeratosis ± Less follicular plugging
± Less basement membrane thickening
± Less dense dermal infiltrate, sometimesconfined to upper dermis
� Papulosquamous form: identical with DLE
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DIF
� DIF from lesional skin positive in 60%
� Band is not as thick an in DLE
� IgG dust like particles described in the
cytoplasm of basal cells
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Tumid lupus
� Only dermal changes
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Dermatomyositis
� Polymyositis
� Skin involvement ± Violaceous, erythematous, scaly
± Face, shoulders, extensor surface of the forearmsand thighs
± Poikiloderma
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± Pruritus
± Heliotrope rash
± Gottron¶s papules
� 10-20% with underlying malignancy
Histology
� Mild vacuolar-interface dermatitis
� Rare apoptotic cells
� Sparse dermal infiltrate, often superficial
� Abundant dermal mucin
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DIF
� Usually negative
� C5b is positive perivascular
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Connective tissue diseaseDLE SCLE Tumid lupus Dermatomyositis
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� Prominent epidermalchanges
� No follicular plugging� No basement
membrane thickening� Sparse dermal infiltrate,
confined to upper dermis
� No epidermal changes� Superficial and deep
dermal infiltrate
� Prominent dermal
mucin
� Follicular plugging� Basement membrane
thickening
� Superficial and deep
dermal infiltrate� Dermal mucin
� Very subtle epidermalchanges
� Very sparse dermal
infiltrate
� Prominent dermalmucin
Cazul 29
� Un pacient de 8 de ani se prezinta cu un
nodul pe fata si o biopsie este efectuata.Care este pasul urmator in tratament? A. Informeaza pacientul si parintii despre natura benigna a acestei
leziuni si programeaza pacientul la controala regulate.
B Programeaza pentru excizie cu margini largi de siguranta
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B. Programeaza pentru excizie cu margini largi de siguranta.
C. Trimite specimenul pentru teste de "fluorescence in situ
hybridization" pentru a stabili natura maligna sau benigna a
tumorii.
D. Trimite specimenul pentru teste de "comparative genomic
hybridization" pentru a stabili natura maligna sau benigna a
tumorii.
Cazul 29
� Un pacient de 8 de ani se prezinta cu un
nodul pe fata si o biopsie este efectuata.Care este pasul urmator in tratament? A. Informeaza pacientul si parintii despre natura benigna a
acestei leziuni si programeaza pacientul la controala regulate.
B Programeaza pentru excizie cu margini largi de siguranta
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B. Programeaza pentru excizie cu margini largi de siguranta.
C. Trimite specimenul pentru teste de "fluorescence in situ
hybridization" pentru a stabili natura maligna sau benigna a
tumorii.
D. Trimite specimenul pentru teste de "comparative genomic
hybridization" pentru a stabili natura maligna sau benigna a
tumorii.
Spitz¶s NevusSpitz¶s Nevus
�� Red colored papule, usually < 1 cm inRed colored papule, usually < 1 cm in
diameter diameter �� Children or young adultsChildren or young adults
�� Common on lower extremities, but canCommon on lower extremities, but can
occur at almost any body siteoccur at almost any body site
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occur at almost any body siteoccur at almost any body site
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S pitz¶s nevus
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Spitz¶s Nevus (micro)
� Symmetry
� Spindled or epithelioid cells� Maturation with increasing depth of dermal
component
� May have some pagetoid spread of
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May have some pagetoid spread of solitary melanocytes (extensive in
pagetoid Spitz)
Spitz¶s Nevus (micro 2)
� Circumscribed nests which separate from
adjacent keratinocytes (clefting)� Multinucleate cells
� Little pleomorphism
� No deep atypical mitoses
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No deep atypical mitoses� Dermal edema/telangiectasia
Cazul 30
� Cel mai probabil diagnostic in acest caz
este: A. Angioleiomiom
B. Leiomiosarcom
C
.C
arcinom squamocelularD D t fib
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. arcinom squamocelular D. Dermatofibrom
E. Leiomiom pilar
Cazul 30
� Cel mai probabil diagnostic in acest caz
este: A. Angioleiomiom
B. Leiomiosarcom
C. Carcinom squamocelular
D D t fib
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D. Dermatofibrom
E. Leiomiom pilar
PILAR LEIOMYOMAPILAR LEIOMYOMA
�� Erector Erector pilipili musclemuscle
�� Multiple lesionsMultiple lesions�� Familial syndrome associated with renalFamilial syndrome associated with renal
carcinoma and uterinecarcinoma and uterine leiomyomasleiomyomas
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Alte optiuni
Angioleiomiom
LeiomiosarcomC arcinom squamocelular
Dermatofibrom
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ANGIOLEIOMYOMAS ANGIOLEIOMYOMAS
�� Clinical:Clinical:
± ± painfulpainful subQsubQ tumorstumors ± ± WomenWomen
± ± 4040 ± ± 60 yrs60 yrs
± ± Lower legLower leg
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gg
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New York, NY, US
QUESTIONS?