Deep Perivascular Lymphocytic Infiltrate Research Articles

32315 Postoperative care consideration: Cold panniculitis induced by cooling device after knee surgery

A 52-year-old female presented with 1-week history of an asymptomatic eruption on the right knee. This started as blanched patches that progressed over a few days to raised urticarial papules. Prior to the onset of the eruption, she had been using a cold therapy device on this knee for 3 weeks after arthroscopy and medial meniscus repair. On examination, there were smooth indurated round papules localized to the right anterior knee. A punch biopsy was obtained revealing a superficial and deep perivascular lymphocytic infiltrate extending into the subcutis, consistent with cold panniculitis.

32315 Postoperative care consideration: Cold panniculitis induced by cooling device after knee surgery

A 52-year-old woman presented with 1-week history of an asymptomatic eruption on the right knee. This started as blanched patches which progressed over a few days to raised urticarial papules. Prior to the onset of the eruption, she had been using a cold therapy device on this knee for three weeks after arthroscopy and medial meniscus repair. On examination, there were smooth indurated round papules localized to the right anterior knee. A punch biopsy was obtained revealing a superficial and deep perivascular lymphocytic infiltrate extending into the subcutis, consistent with cold panniculitis. Cold panniculitis refers to inflammation of the fat following exposure to very cold temperatures. It is most common in the cheeks of young children but has rarely been reported in adults, including in female equestrians and after use of ice packs for chronic lower back pain. There has also been a report of cold panniculitis after use of a cold device after shoulder surgery. Treatment frequently involves removing the source of thermal injury. Our patient was instructed to stop using her cold therapy device and over time her lesions resolved. Given the development and increased availability of such devices, it is possible a similar clinical picture may present more frequently in dermatology clinics in the future.

Histopathologic Features of Chilblainlike Lesions Developing in the Setting of the Coronavirus Disease 2019 (COVID-19) Pandemic.

During the coronavirus disease 2019 pandemic, several studies have described a distinctive cutaneous manifestation with a clinical picture resembling chilblains or chilblain lupus in young patients. To report the histopathologic description of a series of chilblainlike lesions appearing in the context of the severe acute respiratory syndrome coronavirus 2 epidemic. The study included 13 patients with cutaneous acral lesions resembling chilblains occurring in the setting of suspected severe acute respiratory syndrome coronavirus 2 infection with available skin biopsy. Two main histopathologic patterns were observed: a chilblainlike histopathologic pattern (10 of 13 cases; 77%) and a thrombotic vasculopathy pattern (3 of 13 cases; 23%). The chilblainlike histopathologic pattern featured a superficial and deep perivascular infiltrate of lymphocytes of varying intensity. This infiltrate was sometimes peri-eccrine and alterations of eccrine glands were present in most cases. Vacuolar alteration of the basal layer of the epidermis was found in a majority of patients. Lichenoid interface dermatitis was rarely present. The thrombotic vasculopathy pattern featured an absent or mild inflammatory infiltrate, multiple intraluminal fibrin thrombi, and ischemic epidermal necrosis. In both patterns, no true vasculitis was observed. No patient tested positive for severe acute respiratory syndrome coronavirus 2 by polymerase chain reaction, possibly because these lesions may represent late cutaneous manifestations of the disease or are associated with an early effective immune response. The relationship of chilblainlike lesions to severe acute respiratory syndrome coronavirus 2 requires further investigations. Histopathologic features mimic chilblains, chilblain lupus, and, less frequently, a thrombotic vasculopathy. Response to viral infection might trigger diverse mechanisms leading to the 2 histopathologic patterns described.

Lichen Aureus

Lichen aureus (LA) presents an inflammatory infiltrate with a lichenoid pattern, which mainly localizes to the superficial dermis, and it is admixed with extravasated erythrocytes. We present the case of a 12-year-old male who had a 1.3-cm golden-brown-color patch on the right upper back for 2 weeks. Histopathologic examination revealed a lichenoid, superficial, and deep perivascular lymphocytic infiltrate with perineural and periappendageal involvement, extravasated erythrocytes, papillary dermal edema, and hemosiderophages. The perineural and periappendageal infiltrate is unusual for LA and suggestive of lichen striatus (LS). In addition, the presence of perineural inflammation is not a common feature for either LA or LS. However, given the clinical findings, taken together, these features were interpreted as being most consistent with LA. To the best of our knowledge, no previous case of LA has been reported with histological features of perineural inflammation and LS.

Clinical Features and Histological Findings of 17 Patients with Chronic Actinic Dermatitis

ObjectivesThis study was designed to evaluate the clinical, histological and immunohistochemical findings and treatment of chronic actinic dermatitis in Korean patients. MethodsSeventeen Korean patients with chronic actinic dermatitis were enrolled for this study. The clinical and histological findings and the results of phototest were reviewed with medical records, clinical photographs and pathologic slides. We also reviewed the effectiveness of the treatments in all patients with chronic actinic dermatitis. ResultsIn all patients with chronic actinic dermatitis, pruritus was severe, and the patients present in the early stages with erythemas on the face, neck and the back of the hands. As the eruption progresses, it became lichenified and scaly plaques and papules developed. The face, upper extremity and neck were most commonly affected. The most common abnormal results of the phototests were decreased MED-UVB alone. In 8 patients with actinic reticuloid, histopathologic findings showed irregular acanthosis, parakeratosis, spongiosis, atypical hyperchromatic cells with cerebriform nuclei, epidermotropism, Pautrier-like microabscess, deep perivascular lymphocytic infiltrates, vertically-streaked collagen in the papillary dermis, stellate and multinucleated fibroblasts. Treatment includes topical tacrolimus and corticosteroid, oral corticosteroid, azathioprine and cyclosporine. ConclusionsOur study showed classic clinical and histological findings. The most common abnormal results of the phototests were decreased MED-UVB alone. Topical steroid, tacrolimus and systemic cyclosporine, azathioprine are effective in treating chronic actinic dermatitis.

Allopurinol induced granuloma annulare in a patient of lepromatous leprosy

Granuloma annulare (GA) is a benign, inflammatory dermatosis involving dermis or subcutis with unknown etiology and poorly understood pathology. GA has characteristic histological features of necrobiosis, granuloma formation and abundant mucin deposition. Various predisposing factors, systemic diseases and drugs have been implicated in the etiology. We hereby describe a case of 70 year old male who was a known case of lepromatous leprosy, taking multidrug therapy for 6 months presented with multiple discrete, annular, firm, non tender, smooth surfaced skin colored papular lesions ranging in size from 0.5-1 cm over back for 1 month. There was past history of intake of allopurinol for hyperuricemia which was started 1 year back. There was history of similar lesions 6 months back which healed within 1 month of stopping allopurinol and he started taking the drug for the past 4 months on his own without any medical advice. Histopathological examination showed superficial and deep perivascular lymphocytic infiltrate with numerous histiocytes scattered in the intersititum of reticular dermis and abundant mucin in between the histiocytes. Allopurinol was implicated as an etiological agent and dramatic improvement was seen after stopping the drug for a period of 4 weeks. Naranjo's algorithm showed a probable association with a score of 6. Thus the final diagnosis of allopurinol induced generalised interstitial granuolma annulare was made. Patient was advised to continue antileprotic drugs, low purine diet and avoid allopurinol intake.

À propos d’un syndrome EPPER (eosinophilic polymorphic pruritic eruption associated with radiotherapy) survenu chez une patiente après traitement d’un cancer de l’endomètre

Acute and mainly late toxicity is a major concern for radiotherapists. Here, we describe a case of a generalized acute eruption due to radiation, having a superficial and deep perivascular lymphocytic infiltrate with numerous eosinophils found in skin biopsy: the EPPER syndrome (eosinophilic polymorphic pruritic eruption associated with radiotherapy). A patient who had endometrial cancer was treated first by surgery, then radiotherapy developed the day following the end of irradiation a generalized erythematous, pruriginous eruption (pelvis, trunk, lower and upper limbs, neck, face, ears). Different tests with a skin biopsy found a superficial and deep perivascular lymphohistiocytic infiltrate with many eosinophils, confirming an EPPER syndrome. The description of the syndrome was first published in 1999 by Rueda et al. (1999) [1]. Later on, there have only been a few case reports on this subject. This syndrome can be encountered in many cancers, but more frequently in cervix and breast carcinomas and can occur up to nine and a half months after radiotherapy. The pathogenic mechanism is unknown. Antihistamines, topical corticosteroids or oral corticosteroids as well as ultraviolet B therapy have been used successfully to treat EPPER syndrome. Some cases of spontaneous resolution are also described. EPPER syndrome is probably largely underestimated due to its polymorphic characteristics, its occurrence sometimes late after radiotherapy. Its knowledge is essential to inform and treat patients correctly.

Erythema Migrans

Early cutaneous Lyme disease, erythema migrans, manifests as a gyrate erythema at the site of a tick bite. The standard histopathologic description is that of a superficial and deep perivascular lymphocytic infiltrate in which plasma cells are identified at the periphery of the lesion and eosinophils in the center. Deviation from these commonly accepted histopathologic findings may lead to an erroneous diagnosis. Herein, we describe 4 cases of erythema migrans, all biopsied at the periphery of the lesion and confirmed by serologic studies, demonstrating a variety of unconventional histopathologic patterns. These findings include eosinophils and neutrophils at the periphery of the expanding annular plaque of erythema migrans, focal interface change, spongiosis, involvement of the superficial vascular plexus alone, and an absence of plasma cells in all cases. These cases highlight the varied and nonspecific histopathologic changes that can be seen in erythema migrans, including the absence of plasma cells and the presence of focal interface change. Based on these findings, the dermatopathologist should always consider erythema migrans as a diagnostic possibility in a biopsy specimen from an expanding gyrate or annular erythema despite the presence of unusual features. In atypical clinical cases, serologic confirmation may be required for diagnosis in the presence of histopathologic findings considered unconventional for erythema migrans.

Unilateral Eyelid Discoid Lupus Erythematosus

To the Editor: Discoid lupus erythematosus (DLE) involving palpebral areas is estimated to occur in up to 5% of all patients with mucocutaneous DLE.1 These patients typically present with bilateral eyelid involvement and other associated mucocutaneous DLE lesions. Solely unilateral eyelid DLE is exceedingly rare and more commonly associated with delayed diagnosis and potential increased morbidity. We present a patient with unilateral eyelid DLE associated with madarosis, scarring, and mucosal involvement. A 38-year-old, otherwise healthy, woman presented with a 5-year history of an enlarging left lower eyelid lesion associated with pain, edema, and epiphora (Fig. 1). She denied other mucocutaneous lesions, loss of visual acuity, or constitutional symptoms. Previous therapies had resulted in minimal response and included topical triamcinolone 0.1% ointment, mupirocin ointment, and tobramycin plus dexamethasone eyedrop solutions. Physical examination revealed an indurated, erythematous, scaly plaque of the outer aspect of the left lower eyelid. Significant madarosis, early entropion, contiguous erythema, and edema of the inferior palpebral conjunctiva were also noted. No symblepharon or other ocular abnormality was detected on slit lamp and funduscopic examination. Ancillary studies including complete blood cell count, C3, C4, CH50, sedimentation rate, creatinine, urine analysis, antinuclear antibody, anti-dsDNA, rheumatoid factor, anti-ribonucleoprotein, anti-Sm, anti-Ro, and anti-La were negative or within normal limits. Histological evaluation of a 3-mm lesional punch biopsy specimen revealed an interface dermatitis associated with follicular involvement, superficial and deep perivascular lymphocytic infiltrate, increased dermal mucin confirmed with colloidal iron stain, and significant thickening of the epidermal and adnexal basement membrane confirmed with periodic acid-Schiff stain. Direct immunofluorescence evaluation of a 3-mm punch biopsy obtained from lesional skin revealed dense granular immunoglobulin M, C3, weaker immunoglobulin G, and C5b-9 deposits along the epidermal and adnexal basement membrane zone, confirming the diagnosis of DLE (Figs. 2A, B).FIGURE 1: Involving the outer aspect of left lower eyelid, physical examination showed an indurated, pink, erythematous, scaly plaque. Significant madarosis, early entropion, contiguous erythema, and edema of the inferior palpebral conjunctiva were also noted.FIGURE 2: A, Routine histological examination of lesional skin punch biopsy showed a interface dermatitis with hyperkeratosis, few dyskeratotic keratinocytes, thickened epidermal and adnexal basement membrane zones, increased superficial and deep mucin, and perifollicular sebaceous lymphocytic infiltrate. B, On direct immunofluorescence examination of lesional skin punch biopsy, immunoglobulin M, immunoglobulin G, and C3 heavy and thick granular deposition along the epidermal and adnexal basement membrane zone were noted. Few cytoid elements were noted. Indirect immunofluorescence showed no circulating antiepithelial antibodies.She was placed on 40-mg prednisone with a tapering-off regimen for more than 4 months. Mycophenolate mofetil 1 g twice daily and hydroxychloroquine 200 mg twice daily were concomitantly initiated as a corticosteroid-sparing therapy. On 5-month follow-up, significant improvement was noted while she continues on corticosteroid-sparing adjuvants. Eyelid involvement by DLE lesions has significant morbidity including madarosis, ectropion, entropion, scarring, cicatrizing conjunctivitis with symblepharon formation, and eventually blindness.2 Furthermore, DLE lesions that present solely on the eyelids frequently lack the typical clinical morphologic findings of this form of chronic cutaneous lupus erythematosus, imposing a diagnostic challenge and potential delayed therapy.3 Thus, awareness of this atypical presentation of DLE along with adequate sampling including the deep dermis and subcutis for both routine histology and direct immunofluorescence evaluation is crucial for accurate clinical pathologic correlation. Carlos Ricotti, MD University of Miami L. Miller School of Medicine Department of Dermatology Miami FL Elaine Tozman, MD University of Miami L. Miller School of Medicine Division of Rheumatology Miami FL Anthony Fernandez, MD, PhD University of Miami L. Miller School of Medicine Department of Dermatology Miami FL Carlos H. Nousari, MD Dermpath Diagnostics South Florida Pompano Beach FL // University of Miami L. Miller School of Medicine Department of Dermatology Miami FL

Infiltration lymphocytaire dermique précédant un syndrome de Sweet

The histologic criteria for Sweet's syndrome consist in prominent oedema of the dermis and a diffuse infiltrate of numerous neutrophils with leukocytoclasis without vasculitis in the superficial and the deep dermis. Several comorbidities have been observed in patients with Sweet's syndrome, particularly hemo-proliferative diseases. We report the cases of two men aged 60 and 75 years with Sweet's syndrome associated in one case with myelodysplasia and in the other with chronic lymphocytic leukemia. These two patients had typical edematous plaques highly evocative of Sweet's syndrome. However, histological examination revealed superficial and deep perivascular lymphocytic infiltrate in the dermis on 5 occasions before the typical neutrophilic dermatosis of Sweet's could be diagnosed after respectively 2 and 4 years of progression. Histological findings in Sweet's syndrome are characteristic and constitute a major diagnostic factor. However, these two cases show that a lymphocytic infiltrate can occur months or even years before the appearance of typical neutrophilic infiltrate in patients with Sweet's syndrome.

Eosinophilic, polymorphic, and pruritic eruption associated with radiotherapy (EPPER) in a patient with breast cancer

Eosinophilic, polymorphic, and pruritic eruption associated with radiotherapy (EPPER) in a patient with breast cancer

Necrolytic Acral Erythema

A 46‐year‐old hepatitis C‐positive African American woman presented with a several month history of worsening, well‐marginated, erythematous, dusky plaques on the dorsum of her feet and ankles. After an initial skin biopsy showed spongiotic dermatitis, she was treated with emollients, high potency topical steroids, and keratolytics, all of which were of no benefit. A punch biopsy from the dorsum of her foot showed acanthosis, individual keratinocyte necrosis, confluent upper epidermal necrosis, and a superficial and deep perivascular lymphocytic infiltrate. Given the patient's positive hepatitis C status and clinicopathological correlation, a diagnosis of necrolytic acral erythema was rendered. Empiric therapy with oral zinc sulfate was initiated despite a normal plasma zinc level, and the skin lesions resolved with post‐inflammatory hyperpigmentation. Necrolytic acral erythema, considered one of the necrolytic erythemas, is a cutaneous manifestation of hepatitis C virus infection. A total of nine cases have been reported in the literature, seven from Egypt and two from the United States. All reported patients have been hepatitis C positive. This case represents the third reported patient from the US with necrolytic acral erythema.

Return of the painful leg ulcers

A31-year-old man who worked as a landscape gardener was seen because of painful ulcers on his left lower leg that had been recurrent for 3 years. His history included multiple episodes of bilateral deep venous thrombosis in his upper and lower extremities and two episodes of pulmonary embolism during the previous 6 years. His father had a history of recurrent deep venous thrombosis, cerebrovascular accident at the age of 47 years, and seropositivity for lupus anticoagulant. On physical examination, several painful ulcers ranging in diameter from a few millimeters to 2 cm were seen on his left lower leg. A purplish area of livedo over the left fifth toe and scars from previous ulcers also were noted. Laboratory results included: platelets 118×10 3 /μL, a negative antinuclear antibody screen, and a positive antiphospholipid antibody test (138 IgG phospholipid [GPL] units [normal, <15 GPL units]). Factor V Leiden, cryofibrinogen, and cryoglobulin were not detected. A duplex ultrasound scan showed residual deep venous thrombosis extending from the left popliteal vein down through the left peroneal veins. Biopsy of tissue from the left lateral calf revealed a superficial and deep perivascular lymphocytic infiltrate and scattered eosinophils and fibrin thrombi in the deep dermal vessels.

Tumid lupus erythematosus.

Tumid lupus erythematosus (TLE) is a subtype of discoid lupus erythematosus (DLE) whose clinical characteristics rarely have been described in the literature. To describe the clinical, histopathologic, and other laboratory findings in tumid lupus erythematosus. Clinical and laboratory findings were reviewed in four patients who had been diagnosed with tumid lupus erythematosus by conventional microscopy. The diagnoses were characterized by a superficial and deep perivascular infiltrate of lymphocytes and deposits of mucin in foci in the reticular dermis. All four patients were young women. Ages ranged from 16 to 39 years (mean 21 years). The lesions consisted of numerous erythematous papules and plaques, some with annular configuration situated in the face and neck, trunk, and upper extremities. All four patients had concurrent lesions of classic DLE, three of them had systemic lupus erythematosus (SLE). Direct immunofluorescence test results were negative in nonexposed lesional skin of two of the patients. The clinical findings of concurrent lesions of TLE and classic DLE in the same patient, the presence of lesions of TLE in patients with SLE, and the histologic findings demonstrate that TLE is a distinct manifestation of DLE, and as such, a cutaneous expression of SLE.