Clinical Mimicker Research Articles

Zoon's Balanitis - Update of Clinical Spectrum and Management.

Zoon's balanitis or balanitis plasmacellularis circumscripta is a chronic inflammatory disorder of the genital mucosa that can affect both males and females (Zoon's vulvitis). It is not a sexually transmitted disease but can still cause anxiety to the patients because of its chronic nature. Hence, proper diagnosis and early management are necessary. It is a clinical mimicker of other commoner genital dermatoses and is mostly a diagnosis of exclusion when other diseases have been ruled out. It is characterised by a well-demarcated shiny erythematous patch or plaque over the genital mucosa. Histopathological examination becomes necessary when we are unable to differentiate it from premalignant lesions. It reveals lozenge-shaped keratinocytes with siderophages, haemorrhages and variable plasma cell infiltrate in the dermis. Dermoscopy shows spermatozoa-like, convoluted vessels with structureless red orange areas. Response to topical therapy alone is not always satisfactory. However, lasers and surgical management can provide long-term remission.

Monckeberg’s Calcification as a Clinical Mimicker of Temporal Arteritis: A Case Report

Temporal arteritis usually presents in patients above 50 years and is characterised by granulomatous inflammation in all layers of the arterial wall. On the other hand, Monckeberg medial calcification is a disease condition limited to the tunica media of the affected vessels. In this report, authors present the case of a 68-year-old man who presented to the casualty with facial pain. He also had a runny nose, cough, and sleep disturbance. A Computed Tomography (CT) scan was performed and reported as normal. The patient underwent Ear, Nose and Throat (ENT) and Ophthalmology evaluations. Neurology opinion revealed tenderness and thickening of the right superficial temporal artery. Based on clinical suspicion, the patient was started on oral corticosteroids, suspecting temporal arteritis. A temporal artery biopsy was performed for histopathological examination, which surprisingly revealed no evidence of arteritis but only calcification of the tunica media. Unfortunately, the patient was lost to follow-up after the biopsy. This case highlights the importance of recognising Monckeberg medial calcification in clinically suspected cases of temporal arteritis, as there are only a few reported cases in the literature.

S2029 Epiploic Appendagitis: A Red Herring?

Introduction: Epiploic appendagitis (EA) is a rare cause of acute abdominal pain that has a relatively benign course. The importance of identifying EA as a clinical mimicker is crucial to avoid unnecessary hospitalizations, antibiotic use, and surgery. Although no trigger has been established as a cause for EA, it is hypothesized that systemic inflammation can lead to an EA attack. Case Description/Methods: A 43-year-old White female with no significant GI history presented with 2 days of sudden onset, sharp, non-radiating, worsening left lower quadrant (LLQ) with nausea. Initial blood work was unremarkable. CT abdomen revealed a hyper-attenuating ring lesion along the anti-mesenteric margin adjacent to the distal descending colon, along with mesenteric lymph nodes consistent with epiploic appendagitis. She was managed conservatively with complete resolution of symptoms. A few years later, she presented again, with similar abdominal complaints. Repeat abdominal imaging showed recurrence of EA in the same location. Few shotty mesenteric lymph nodes were identified. She was treated conservatively for EA. A few more years passed, and she now had another episode of recurrent LLQ pain, CT abdomen showed findings consistent with EA along with a short segment of mural thickening and mild hyper-enhancement in the mid descending colon. Colonoscopy revealed a large circumferential mass in the sigmoid colon with an apple core lesion in the proximal sigmoid colon with luminal narrowing. Biopsy revealed an adenocarcinoma. No lymph node involvement was noted. As the TNM staging was pT3 N0 M0, she underwent a sigmoidectomy with left colon and rectal end-to-end anastomosis (Figure). Discussion: Epiploic appendages are fat-filled serosal outpouchings of the colonic surface. They are connected to the colon by a vascular stalk. Acute epiploic appendagitis is theorized to be caused by torsion, underlying inflammation, or venous occlusion of the appendage. CT scan is the gold standard for diagnosing EA and helps rule out other intra-abdominal pathologies. Recurrent and persistent EA is very rare and may mask an underlying occult abdominal pathology. There have not been any reported cases of CRC that are associated with and possibly trigger EA. In patients with recurrent EA, after common causes of acute abdominal pain are ruled out, evaluation for intestinal/intraluminal pathologies, especially colorectal malignancy should be considered as they are not readily apparent on CT scans.Figure 1.: A: Red arrow showing an inflamed epiploic appendage during initial presentations. B: Red arrow showing epiploic appendagitis. Green arrow with colonic wall thickening in the descending colon, with adjacent EA. 3: Colonoscopy showing the large friable mass in the sigmoid colon.

Clinical mimickers of epidermoid cyst in scalp: a retrospective histopathological study

Background: Cystic lesions of the scalp with a clinical diagnosis of an epidermoid cyst are encountered in clinical practice. However, these lesions had a different diagnostic interpretation on histopathology examination. Therefore our study focused on the lesions clinically resembling the presentation of epidermoid cyst in the scalp region. Materials and Methods: Forty-one cases of scalp lesions with a clinical diagnosis of epidermoid cyst over 2 years were reviewed. Details of the patients such as clinical diagnosis, age, gender, duration, gross findings, and histopathology diagnosis were obtained from the medical and histopathology records. Results: Epidermoid cysts diagnosed both clinically and on histopathology examination accounted for 29.26% whereas the clinical mimickers constituted 70.73%. The mean age of the patient was 35-years with an equal sex ratio. The commonest location was the parietal region (41.37%). Benign and malignant lesions consisted of 97.56% and 2.4% respectively. A trichilemmal cyst was the most common clinical mimicker diagnosed. Conclusions: Clinicians should be aware of wide differential diagnosis of epidermoid cyst in the scalp region as the management and outcome vary with each lesion. Histopathology examination proved to be a diagnostic tool in differentiating these lesions.

Congenital hepatic fibrosis and its mimics: a clinicopathologic study of 19 cases at a single institution

BackgroundCongenital hepatic fibrosis (CHF) is a rare inherited form of ductal plate malformation associated with polycystic kidney disease. The diagnosis requires histopathologic confirmation, but can be challenging to distinguish from other undefined fibrocystic liver diseases. We aimed to describe the clinicopathologic features of congenital hepatic fibrosis (CHF), with comparisons to other entities that may clinically and/or histologically mimic CHF.MethodsNineteen cases that carried a clinical and/or histologic impression of CHF were identified at our institution, of which the histology was reassessed and reappraised into two categories: CHF (n=13) and mimics (n=6). The clinicopathologic features between the two groups were analyzed and compared.ResultsThe CHF group was further sub-classified into those with clinical suspicion (CHF-c, n=8) and those as incidental histology findings (CHF-i, n=5). Patients of CHF-i were much older than CHF-c or mimics (P<0.05). Male and female were equally affected. Six of 8 CHF-c (66.7%) had concurrent kidney diseases, including 5 polycystic kidney diseases. Five of 6 mimics (83.3%) had various kidney diseases, including nephronophthisis, Alport syndrome, renal agenesis, and nephrolithiasis. None of the CHF-i patients had kidney disease, but 3 were associated with hepatic carcinomas. Histology analysis demonstrated characteristic triads (bile duct abnormalities, portal vein hypoplasia, and fibrosis) in all CHF cases. One mimic had paucity of intrahepatic bile ducts, while the other 5 mimics showed abnormal portal veins and nodular regenerative hyperplasia consistent with hepatoportal sclerosis (HPS).ConclusionsOur study demonstrates classic histology triad of CHF despite a wide spectrum of clinical presentations. HPS is unexpectedly a clinical mimicker of CHF, which can be distinguished histologically.

Tumid Lupus Erythematosus: A Rare and Distinctive Variant of Cutaneous Lupus Erythematosus Masquerading as Urticarial Vasculitis

Tumid lupus erythematosus (TLE) is a rare form of chronic cutaneous lupus that has triggered much debate regarding its clinical and histopathological features. It has been classically defined as annular erythematous, succulent, plaques involving the face and trunk that typically are devoid of any papulosquamous features such as scale and follicular plugging. These lesions are a clinical mimicker of other urticarial lesions such as urticarial vasculitis and lymphocytic infiltrate of Jessner. We report a case of TLE presenting in a 49-year-old Caucasian female whose initial clinical presentation was concerning for urticarial vasculitis due to presence of urticarial-like lesions present for approximately three months. Laboratory studies and histopathological correlations confirmed the diagnosis of TLE and the patient was successfully treated with topical corticosteroids.

Langerhan's Cell Histiocytosis Masquerading as Intertrigo

Cutaneous Langerhan’s cell histiocytosis (LCH) is considered a great clinical mimicker and affects the scalp and intertriginous regions although it may be generalized. Cutaneous LCH is commonly misdiagnosed and thus patients can receive inadequate or inappropriate treatment for considerable periods of time. We present a case report of a patient who had LCH that was masquareding as intertrigo for years. With the proper diagnosis the patient had a remarkable response to methotrexate. This case highlights the importance of keeping Langerhan’s cell histiocytosis (LCH) on the differential and once the diagnosis is made, evaluating for extracutaneous LCH.

Guillain Barre Syndrome-like Presentation of Subacute Combined Degeneration of Spinal Cord and Association with Neuroendocrine Tumour of GIT

Subacute combined degeneration (SCD) refers to the gradually progressive myelopathic or myeloneuropathic presentation of vitamin B12 deficiency. While polyneuropathy has been well recognised with vitamin B12 deficiency, it has been debated whether neuropathy can manifest in isolation without myelopathy. SCD would seldom pose as a clinical or electrophysiological mimicker of Guillain-Barre syndrome (GBS). We describe the case of a middle age gentleman who presented with two weeks of rapidly progressive sensory predominant neuropathic syndrome with conduction findings consistent with a demyelinating process. In view of certain clinical-electrical discrepancies patient was further imaged with MRI revealing features classical of SCD with nearly undetectable Vitamin B12 levels. Upper gastrointestinal endoscopy as part of evaluation revealed a polyp in body of stomach with histopathological diagnosis of WHO II neurogastroendocrine tumour (carcinoid tumour) along with chronic atrophic gastritis. As far as to our knowledge, the association between gastric carcinoid and SCD have not been reported. We also discuss the relevant clinical points of this GBS-like presentation of SCD and possible pathomechanisms of the association with carcinoid. With parenteral Vitamin B12 supplementation patient had near complete resolution of symptoms and improvement in conduction parameters on follow-up.

Intrathoracic Castleman's disease: "An important clinical mimicker".

Intrathoracic Castleman's disease: "An important clinical mimicker".

Prostatic Blastomycosis: An Infrequent Cause of Granulomatous Prostatitis

Background: Granulomatous prostatitis is an uncommon inflammatory process of the prostate, which in most cases, is nonspecific. Clinical presentation, treatment, and evolution are similar to those of benign prostatic hypertrophy, but this lesion is also a clinical mimicker of prostate. Fungal granulomatous prostatitis is rare and there are only a few reported cases. Clinical case: We report the case of a patient diagnosed with prostatitis blastomycosis. The patient had obstructive and irritative lower urinary tract symptoms, which showed slight improvement the first days of medical treatment. Finally, he underwent transurethral resection of the prostate due to the persistence of the obstructive symptoms. Results: The histopathologic result showed granulomatous prostatitis with features of blastomycosis fungal structures. Diagnosis was confirmed through molecular biology techniques. Conclusion: Despite its low incidence, the diagnosis of fungal granulomatous prostatitis is important to keep in mind, because it can mimic other prostatic pathologies.

Mo1856 Amoebic Colitis? The Great Clinical and Pathological Mimicker: A Case Series

Mo1856 Amoebic Colitis? The Great Clinical and Pathological Mimicker: A Case Series

Severe hypersensitivity reaction to anti-tuberculosis drugs DRESSed as an infectious disease: What can be done to improve awareness?

Severe hypersensitivity reaction to anti-tuberculosis drugs DRESSed as an infectious disease: What can be done to improve awareness?

DemodexFolliculitis Mimicking Acute Graft-vs-Host Disease

Acute graft-vs-host disease (GVHD) typically requires high-dose systemic steroids as first-line treatment. Like drug eruptions, viral exanthema, and toxic erythema of chemotherapy, Demodex folliculitis is a clinical mimicker of acute GVHD and requires nonimmunosuppressive therapy. This case of Demodex folliculitis mimicking acute GVHD highlights the need for skin biopsy in patients who have undergone a stem cell transplant with eruptions on the head and neck. A 46-year-old white woman with a history of Fms-like tyrosine kinase 3 acute myeloid leukemia presented to the dermatology clinic with a 5-day history of a nonpruritic eruption on her face and neck 28 days after undergoing a double umbilical cord blood hematopoietic stem cell transplant (HSCT). Findings from the skin biopsy demonstrated a deep dermal lymphocytic infiltrate adjacent to follicular units along with an abundance of Demodex mites noted within the hair follicles consistent with Demodex folliculitis. Oral ivermectin, 12 mg, was given, and the eruption cleared within 24 hours. To our knowledge, this is only the fifth reported case of Demodex folliculitis following HSCT, but the first ever reported to be successfully treated with oral ivermectin. Demodex folliculitis should be added to the differential diagnosis of skin eruptions that arise after HSCT.

Misdiagnosis of Knee Venous Malformation as Juvenile Idiopathic Arthritis

Initial clinical presentation of knee venous malformation can mimic that of juvenile idiopathic arthritis, posing a diagnostic dilemma. In this communication, we discuss the diagnostic challenges encountered in children with venous malformation of the knee who were misdiagnosed as having juvenile idiopathic arthritis. We highlight the clinical and imaging differences between these 2 disorders with the goal of preventing these diagnostic pitfalls in the future. We conducted a comprehensive search of our databases at Children's Hospital Boston over the last 11 years (1999 to 2009) for patients with venous malformation of the knee who were initially given the diagnosis of juvenile idiopathic arthritis. A retrospective review of the medical records, photographs, and imaging studies was performed. Of the 56 patients found to have venous malformations of the knee, 6 patients (0 to 13 y, 4 females) were initially misdiagnosed as juvenile idiopathic arthritis and managed as such. Five of the 6 patients received nonsteroidal anti-inflammatory drugs. Of these 5, corticosteroids were also administered in 2 patients, and 1 also received methotrexate. One patient was treated conservatively. Venous malformation of the knee can present as a clinical mimicker of juvenile idiopathic arthritis. Familiarity with the clinical presentation and imaging findings of these 2 disorders should minimize misdiagnosis of knee venous malformation as juvenile idiopathic arthritis and thus avoid inappropriate or delayed therapy. Types of Studies: Diagnostic Studies-Investigating a Diagnostic Test, Level III.

Metastatic eyelid disease in 49 cases

The literature regarding metastatic eyelid disease has consisted of isolated case reports or small series. The author updates his review of metastatic lid disease to include a series of 49 cases and compare the results with a literature review of 88 cases. Metastatic lid disease is a disease of elderly women, with the breast being the primary focus in half of the cases. Metastatic lid disease is a great clinical mimicker. Metastasis should be suspected in patients with known malignancies when presenting with an eyelid lesion.