Dermal Lymphocytic Infiltrate Research Articles

Gross and Histopathological Study of Postscabietic Nodules

Background: Nodular postscabietic scabies refer to the persistent intermittent signs of scabies that are seen in active and post-treatment period that might last for months. The spectrum of clinico-morphological ranges that can be observed with sarcoptic nodules is broad, and most of the entity's criteria can be elicited histopathologically and pathologically. The management of such nodules may be a challenge. They are commonly treated through local application of corticosteroids or injection of corticosteroids to nodules but the response to treatment is less than clent and relapses are very frequent. The objective of this study was to illuminate which of these features prevail and which ones fade in scarred sites which undergo postscabietic nodule development. The time span between August 2021 to May 2022 was allowed to collect samples from patients with (1-60) years old and full of scabies burrows who visit teaching hospitals and private dermatology clinics in Kut, Wasit Province, Iraq. Treat groups were split into 30 females, and 20 males; with persistent itchy nodular lesions of scabies demonstrated clinically and histopathologically. Everity grade scabies was evaluated by the number of lesions and rated it as severity of itching. Long-term treatment with topical glucocorticoids for 14 days in every age. Tissue from the blisters of patient was obtained after medication. The specimens were washed, fixed and cut to 4-5 µm and stained with H&E. The staining allowed us to observe the fragments of tissues under light microscope with different magnification power. We have observed excessive males and the prevalence of SCABies were more in a young adult group in comparison with other age groups. It was found that lesions with wiry projections tended to persist for two weeks to 52 weeks and the number of nodules had varied from one to fourteen lesions. Examination of Histopathological slide showing acanthosis in 80, histolymphocytic infiltration in 76, and eosinophilia in 100 of total cases in the whole period. After the scabitic nodule loop, the body experiences a hypersensitivity reaction. From the three hundred cases examined microscopically, most (80%) of them were found to be characterized by acanthotic epidermis and diffuse dense dermal lymphocytic infiltration. Neutrophilic reaction, epithelioid-granulomatous inflammation and eosinophilia have been diagnosed in 76 % sight upon while 100 % of other nodules have shown eosinophilia.

Primary Cutaneous Acral CD8-Positive Lymphoproliferative Disorder: A Case Report With Nonacral Presentation.

In this study, we describe a patient of primary cutaneous acral CD8-positive lymphoproliferative disorder located in a nonacral region. A 65-year-old male presented with an ill-defined lesion of rubbery consistency and a maximum diameter of 2.5 cm localized in the right thigh. Histologically, it was composed of a diffuse dermal infiltration of medium-sized atypical lymphocytes that expressed CD3, CD8, and TIA-1. In addition, a characteristic paranuclear positivity with CD68 was observed. During the follow-up, the patient had a recurrence of the disease in the abdomen with a lesion showing similar morphology and phenotype. To our knowledge, < 20 patients of primary cutaneous acral CD8-positive lymphoproliferative disorder with a nonacral presentation have been described in English literature. Although rare, its identification is essential to differentiate it from other T-cell lymphoma that express CD8 and cytotoxic markers, and whose clinical courses are very aggressive.

Clinical and molecular detection of fowl pox in domestic pigeons in Basrah Southern of Iraq

Bird species, particularly poultry and other bird types, including domestic pigeons, are susceptible to fowl pox, a contagious viral disease. The main goal of this study was to validate clinical avipoxvirus diagnoses using molecular analytical methods. The essential components of the investigation were the clinical signs, visible abnormalities, histological changes, and polymerase chain reaction analysis. Twenty out of 120 pigeons had clinical symptoms, which included yellowish crust or nodules near the feet, eyes, and beak. An erosive epidermal lesion and an epidermal acanthotic papular lesion with basal vacuolation were maculopapular evidence associated with significant epidermal hyperkeratosis, as confirmed by histological analysis. In addition, the results showed keratinocyte necrosis beneath the hyperkeratotic epidermal layer, together with superficial and deep dermal perivascular lymphocytic infiltration. In addition, the P4b core protein gene underwent phylogenetic analysis. The sequence analysis results indicated a high degree of similarity across the local strains, with just minor variations observed. Five sample sequences were selected and submitted to the NCBI database. These sequences were identified as OR187728, OR187729, OR187730, OR187731, and OR187732. All the various strains in this research may be classified under clade A of the chicken pox virus phylogenetic classification. This study presents the first description and characterization of pox virus infections in domestic pigeons inside the Basrah governorate.

Darier disease: Histopathology revisited.

Darier disease (DD) is a rare genodermatosis. Literature on this topic is overwhelmingly dominated by case reports with rare clinical presentations, which have mentioned the histopathologic features briefly. The aim of this study was to document the histopathology of DD. Skin biopsies diagnosed as Darier disease based on clinicopathologic correlation over 12 years were reviewed for various epidermal and dermal features. There were 16 patients included, who most commonly presented in the third decade, with slight female predilection. The most common clinical presentation was hyperpigmented, hyperkeratotic, papules and plaques (91%), with 69% affecting the trunk. In addition to the classic suprabasal acantholytic clefts, we noted some unusual features: absence of parakeratosis (19%), a cornoid lamella-like pattern (62%), follicular acantholysis (13%) and multiple foci of involvement within a single biopsy (63%). Features such as the presence of dyskeratotic cells and minimal dermal lymphocytic infiltrates were concordant with previous literature. The limitation of this study was the small sample size. To conclude, pathologists must be aware of the variations in histopathology of Darier's disease, especially when challenged with atypical clinical presentations. The Darier-like pattern is met within several acantholytic diseases, and clinicopathologic correlation has the last word in arriving at a diagnosis.

Clinicopathologic Overlap of Vulvar Psoriasis and Candidiasis.

The study's aim is to assess if vulvar psoriasis and candidiasis may be distinguished by clinical presentation and histopathologic appearance. The pathology database identified biopsies with corneal or subcorneal neutrophils, acanthosis, and dermal lymphocytic infiltrate. Exclusions were age younger than 18 years and unavailable or uninterpretable slides. Clinical data included demographics, comorbid conditions, symptoms, examination, microbiology, treatment, and response. Histopathologic review documented site, thickness, and characteristics of stratum corneum and epidermis, distribution of neutrophils, and infiltrate. Cases were stratified by microbiologic presence or absence of Candida albicans. Biopsies from 62 women with median age of 60 years were associated with C. albicans on vulvovaginal culture in 28 (45%), whereas 26 (42%) were negative, and 8 (13%) lacked microbiologic assessment. Swab-positive women were more likely to have diabetes, receive prereferral estrogen, and report vulvar pain. Specialist clinical impression was candidiasis in 33 (53%), psoriasis in 11 (18%), comorbid candidiasis and psoriasis in 7 (11%), dermatitis in 10 (16%), and unknown in 2 (3%). Visible fungal organisms occurred in 16 (26%) cases and were associated with diabetes and satellite lesions. Other than presence of organisms, there were no histopathologic differences stratified by microbiologic result. The histopathologic triad of corneal/subcorneal neutrophils, acanthosis, and dermal lymphocytic infiltrate is common to vulvar psoriasis and candidiasis, and clinical features do not reliably distinguish between them. Microbiologic assessment and single-agent treatment are useful strategies to clarify the diagnosis.

Cutaneous Toll-like Receptor 9 Pre-Defines Hydroxychloroquine Dosage in Patients with Both Discoid and Subacute Lupus Erythematosus.

Background and Objectives: Cutaneous lupus erythematosus (CLE) presents clinically heterogeneous manifestations, partially explained by the different expression of Toll-like receptors (TLRs) type 8 and 9, located to endosomal compartments where they are poised to recognize microbial nucleic acids. This disease is empirically treated with hydroxychloroquine (HCQ), which is hallmarked with a safe and effective profile, but induces a slow and sometimes clinically insufficient therapeutic response. Currently, no biomarkers predictive of response are validated or even proposed in the scientific literature. We aimed to evaluate endosomal TLR type 7, 8 and 9 as predictive biomarkers of HCQ efficacy. Materials and Methods: We conducted a case-control study comparing CLE patients retrospectively assigned to three subgroups based on 3-6-month Cutaneous LE Disease Area and Severity Index (CLASI) reduction upon treatment with HCQ (I = <40% vs. II = 40-80% vs. III = >80%). Before HCQ, lesional skin specimens were collected in untreated CLE and through immunohistochemistry; TLR-7, -8 and -9 expression was evaluated in the epidermis and the lymphocytic infiltrate was evaluated in the dermis. Results: Sixty-six lesional skin biopsies were compared with healthy controls. CLE patients displayed lower epidermal expression of total TLR 8 and 9 as well as infiltrating TLR-8, TLR9 + lymphocytes compared to controls. High HCQ responders differed from low responders for TLR-9 positivity (high vs. low) and for the lymphocytic dermal infiltrate (high vs. low). Conclusions: TLR9 could be envisaged as a possible biomarker to predict HCQ response level and dosage in CLE patients.

DP22 Cutaneous lymphoid hyperplasia: clinicopathological correlation and a therapeutic option

Abstract Cutaneous reactive lymphoid hyperplasia, also known as cutaneous pseudolymphoma, is an uncommon entity in which there are skin lesions that histologically, and sometimes clinically, mimic cutaneous lymphoma but are not, both morphologically and immunohistochemically. Correlating clinical, pathological, immunohistochemical and, occasionally, molecular findings is essential for the diagnosis (Romero-Perez D, Blanes Martinez M, Encabo-Duran B. Pseudolinfomas cutaneous. Actas Dermosifiliogr 2016; 107:640–51). Although the majority of cases can be regarded as idiopathic, certain infections and inflammatory conditions can precipitate cutaneous reactive lymphoid hyperplasia, examples of which include Borrelia infection, insect bite reactions and folliculitis (Mitteldorf, C, Kempf, W. Cutaneous pseudolymphoma – a review on the spectrum and a proposal for a new classification. J Cutan Pathol 2020; 47:76–97). The first case was an 18-year-old woman who presented with deep dermal and subcutaneous nodules for the last 5 years that started on her limbs and were slightly itchy. The nodules were firm and deep, with minimal surface changes (hyperpigmentation and adherent scale) but did not ulcerate. She also had nodules involving her buccal mucosa, inner lips and soft tissue in the nasal bridge and a couple of deep nodules on the cheeks. Pathological examination showed a dense lymphocytic infiltrate with plasma cells admixed with other inflammatory cells involving the deep dermis with an extension to the dermal/subcutaneous junction. The pathological picture was in the spectrum of deep tumid lupus/lupus panniculitis overlap and cutaneous lymphoid hyperplasia. Immunohistochemical stains showed a mixture of inflammatory cells with CD3+ and CD20+ cells. Lip mucosal biopsy showed florid reactive lymphoid follicular hyperplasia. Her condition was resistant to multiple systemic treatments. Eventually, she underwent treatment with rituximab and had satisfactory results. The second patient is an elderly female who had multiple erythematous papules, plaques and nodules on her face. Pathological examination showed a dense dermal lymphocytic infiltrate with periadnexal predilection and reactive follicles that also were highlighted by CD20, with Bcl2 and CD3+ cells around germinal centres. She was diagnosed as having cutaneous reactive lymphoid hyperplasia. Topical calcineurin inhibitors were initiated, with a good response. In conclusion, this paper highlights the term cutaneous pseudolymphoma/cutaneous reactive lymphoid hyperplasia, presenting a few cases with clinicopathological correlation and exploring some uncommon treatment options.

Salt-and-Pepper Dyspigmentation with Groove Sign in Erasmus Syndrome: A Double Jeopardy.

Salt-and-Pepper Dyspigmentation with Groove Sign in Erasmus Syndrome: A Double Jeopardy.

Dermoscopic Features of Lichenoid Pseudovesicular Papular Eruption of the Nose (LiPEN): A Rare Entity.

Dermoscopic Features of Lichenoid Pseudovesicular Papular Eruption of the Nose (LiPEN): A Rare Entity.

A Rare Case Report of T-Cell Rich Angiomatoid Pseudolymphoma.

Dear Editor, Cutaneous pseudolymphoma (PSL) is a reactive lymphoproliferation that histopathologically and/or clinically imitates cutaneous lymphomas. It can be either B-cell or T-cell predominant, and they are further divided into four main categories. Our case falls under the category of T-cell rich angiomatoid PSL.[1] An 86-year-old male presented with multiple, itchy skin lesions over his face, forearms, back, and legs for the past eight months. He was a known case of type 2 diabetes mellitus and right radical nephrectomy was done for Grade II right clear cell renal cell carcinoma six years ago. Cutaneous examination revealed multiple, erythematous infiltrated papules and plaques over the forehead [Figure 1] and lateral aspect of the face. A few hyperpigmented papules with central crusting were seen over bilateral legs and lower back. Angiolymphoid hyperplasia with eosinophilia (ALHE) and Jessner lymphocytic infiltrate of the skin were considered as differential diagnoses. Histopathology of an erythematous infiltrated papule over the forehead revealed a grenz zone and a fairly defined lesion in the dermis [Figure 2]. Many vascular channels lined by hyperplastic endothelial cells were seen in the lesion. Perifollicular mixed inflammatory cell infiltrates comprising histiocytes, lymphocytes, and a few neutrophils were also seen [Figure 3]. IHC showed lymphocytes with strong membranous staining for CD 3 [Figure 4a], and a few showed CD 20 staining [Figure 4b]. A diagnosis of T-cell-rich angiomatoid PSL was made based on histopathology and IHC.Figure 1: Multiple erythematous, few hyperpigmented infiltrated papules, and plaques seen over foreheadFigure 2: Grenz zone (black arrow) and a fairly defined lesion is seen in the dermis (H and E, 10×)Figure 3: The lesion in the dermis shows many vascular channels lined by hyperplastic endothelial cells (red stars). Perifollicular mixed inflammatory cell infiltrates comprising histiocytes, lymphocytes, and few neutrophils were also seen in the lesion (H and E, 100×)Figure 4: (a) Strong membranous staining of the lymphocytes for CD3. (b) Few lymphocytes show CD 20 staining (IHC)Cutaneous PSL is restricted to cases that histopathologically simulate cutaneous lymphomas but do not fit into any other diagnosis after clinical correlation. Some of the etiological factors of PSL include infections caused by bacteria, viruses, parasites, drugs such as anticonvulsants and antihypertensives, foreign agents such as tattoo dyes, injectable vaccinations, insect bites, and ultraviolet radiation. Cutaneous PSL is divided into four main groups based on histopathologic features and clinical data, which include nodular PSLs, PSLs as simulators of Mycosis fungoides (“pseudo-MF”) and of other CTCLs, other PSLs, and intravascular PSLs. Our case clinically and histopathologically fits into the other PSLs group, which comprises T-cell rich angiomatoid PSL and cutaneous plasmacytosis. Acral Pseudolymphomatous Angiokeratoma of Childhood (APACHE), T-cell-Rich Angiomatoid Polypoid Pseudolymphoma (TRAPP), primary cutaneous angioplasmocellular hyperplasia, and lymphoplasmacytoid plaque (LPP) are all forms of T-cell rich angiomatoid PSL.[1] Our case did not show any eosinophils in the inflammatory infiltrate which are characteristically observed in ALHE and the histopathological features observed in our case does not correlate with Jessner lymphocytic infiltrate of the skin. Histopathologically, APACHE and TRAPP were considered as differential diagnoses, but features were more suggestive of TRAPP. Microscopically, TRAPP shows numerous vessels with plump endothelia, a grenz zone, and a dense dermal infiltrate of lymphocytes with a predominance of CD3 over CD20 cells, as seen in our case. TRAPP usually presents as a solitary polypoidal lesion, but in our case it presented atypically as multiple grouped erythematous papules.[2,3] Review of a series of 19 cases showed that a variety of names have been suggested such as APACHE, TRAPP, angiolymphoid hyperplasia with high endothelial venules (ALH-HEV), etc., for lesions sharing similar features such as vascular proliferation with a dense lymphoid infiltrate. They constitute a spectrum of vascular lesions with considerable histopathological and clinical overlap.[4] A case of PSL of the liver in association with renal cell carcinoma occurring 14 months after right radical nephrectomy has been reported.[5] However, our patient developed PSL of the skin post-nephrectomy. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

33521 Two cases of oral baricitinib associated papular eruption on face

Background: Janus kinase (JAK) inhibitors reduce inflammation by interrupting JAK-STAT pathway and are used for various disease. However, cutaneous adverse effects including reactivation of herpes simplex virus, herpes zoster, disseminated molluscum contagiosum, and acneiform eruptions were reported. In addition, few cases of granulomatous inflammation after JAK inhibitor use have been reported recently. Methods: Patient 1, a 40-year-old woman, presented with erythematous papules on periorbital and perioral area for 13 months. She had been taking prednisolone and hydroxychloroquine for rheumatoid arthritis (RA) for 1 year, but symptoms were not controlled. Thus, oral baricitinib was administered. After 2 months, facial lesions appeared. Patient 2, a 64-year-old woman, presented with erythematous papules on face developed 2 weeks ago. She has been taking baricitinib for RA because of inadequate response to methotrexate. Facial eruption occurred 4 months after initiation of baricitinib. Results: For patient 1, histopathologic examination showed dense dermal infiltration of lymphocytes, histiocyte and few plasma cells, which implicated granulomatous dermatitis. Doxycycline and topical gentamycin/prednicarbate were given and the lesions showed response. Patient 2 showed improvement after treatment with doxycycline, topical metronidazole, and topical ivermectin. However, lesions aggravated 7 months after doxycycline cessation with continuous baricitinib use. Conclusion: Although JAK inhibitors are known to be effective for the treatment of granulomatous diseases like sarcoidosis, granulomatous drug eruption has been reported. In our cases, facial skin lesions appeared 2 and 4 months after starting baricitinib, respectively. Our cases imply that dermatologists should be aware of the potential association between JAK inhibitors and cutaneous eruption.

33521 Two cases of oral baricitinib associated papular eruption on face

Background: Janus kinase (JAK) inhibitors reduce inflammation by interrupting JAK-STAT pathway and are used for various disease. However, cutaneous adverse effects including reactivation of herpes simplex virus, herpes zoster, disseminated molluscum contagiosum, and acneiform eruptions were reported. In addition, few cases of granulomatous inflammation after JAK inhibitor use have been reported recently. Methods: Patient 1, a 40-year-old woman, presented with erythematous papules on periorbital and perioral area for 13 months. She had been taking prednisolone and hydroxychloroquine for rheumatoid arthritis (RA) for 1 year, but symptoms were not controlled. Thus, oral baricitinib was administered. After 2 months, facial lesions appeared. Patient 2, a 64-year-old woman, presented with erythematous papules on face developed 2 weeks ago. She has been taking baricitinib for RA because of inadequate response to methotrexate. Facial eruption occurred 4 months after initiation of baricitinib. Results: For patient 1, histopathologic examination showed dense dermal infiltration of lymphocytes, histiocyte and few plasma cells, which implicated granulomatous dermatitis. Doxycycline and topical gentamycin/prednicarbate were given and the lesions showed response. Patient 2 showed improvement after treatment with doxycycline, topical metronidazole, and topical ivermectin. However, lesions aggravated 7 months after doxycycline cessation with continuous baricitinib use. Conclusion: Although JAK inhibitors are known to be effective for the treatment of granulomatous diseases like sarcoidosis, granulomatous drug eruption has been reported. In our cases, facial skin lesions appeared 2 and 4 months after starting baricitinib, respectively. Our cases imply that dermatologists should be aware of the potential association between JAK inhibitors and cutaneous eruption.

The mixed spongiotic and interface reaction pattern: A study of clinical and histopathologic findings.

Categorization of biopsy specimens into inflammatory reaction patterns is central to dermatopathologic assessment. Mixed inflammatory patterns are poorly characterized and may represent clinicopathologic challenges. The purpose of this study was to identify clinical and histopathologic findings associated with the mixed spongiotic-interface dermatitis (SID) histopathologic pattern. Fifty-one institutional biopsy specimens of SID were identified over a 2-year period by retrospective natural language search. Histopathologic and clinical features were identified. The most common histopathologic features associated with SID were mild spongiosis (51%), focal vacuolar interface change (72%), lymphocytic exocytosis (92%), and superficial-dermal lymphocytic infiltrate (94%) with variable eosinophils (61%). Clinically, 80% of subjects presented with a symmetric morbilliform eruption. Polypharmacy (94%), immunosuppression (47%), and history of malignancy (47%) were common. The most common diagnoses were drug reaction (37%), possible drug reaction (12%), and viral exanthem (12%). Drug reaction with eosinophilia and systemic symptoms represented 25% of all confirmed cutaneous adverse drug reactions (CADR). Average time from drug initiation to symptom initiation was 20 days (SD: 22.3, range: 0-90); median disease duration was 25.5 days. Spongiotic vesicles and Langerhans cells were less common in patients with a strong clinicopathologic diagnosis of drug reaction compared to non-drug eruptions (p =0.04). The mixed SID pattern is commonly encountered in CADR but may represent a more subacute course, implying consideration for inciting medication(s) started before the typical 7- to 14-day window.

Solitary pink papule in an elderly man

Solitary pink papule in an elderly man

Tre-P-05 - Use of mogamulizumab for refractory Sézary syndrome in real clinical practice: report of three cases

Sézary syndrome (SS) is a cutaneous T cell lymphoma (CTLC) with poor prognosis which can present de novo or secondary to mycosis fungoides (MF). We report our experience treating patients with SS with mogamulizumab (n=3). <h3>Case 1:</h3> A 76-year-old woman presented with an 8-year history of refractory erythroderma. Skin biopsy showed dermal lymphocytic infiltrate with aberrant phenotype. Blood flow cytometric analysis detected 77% pathologic T-lymphocytes (TL) with SS phenotype and positive T-cell receptor (TCR) ϒ gene rearrangement. Lymph node biopsy showed SS infiltration. She was diagnosed with stage IVA1 SS (T4N1M0B2). Due to disease progression after treatment with bexarotene, mogamulizumab was started following the usual protocol. Patient achieved complete clinical response (CR) since the 2nd infusion in skin, blood and lymph nodes. She presented grade IV neutropenia after the 6th infusion which resolved with filgastrim, and a grade II lymphopenia after the 5th infusion which resolved with posology spaced to every 6 weeks. Patient continues disease-free after 12 months of treatment. <h3>Case 2:</h3> A 66-year-old woman presented with a 1-year history of erythroderma. Skin biopsies were consistent with MF. Blood flow cytometric analysis detected 59.2% of pathological TL with SS phenotype and positive TCR ϒ gene rearrangement. Lymph node biopsy showed SS infiltration. Diagnosis of stage IVA2 SS (T4N3M0B2) was stablished. She was treated with extracorporeal photopheresis, interferon α-2B, bexarotene and gemcitabine with partial response. Treatment with mogamulizumab was started with complete CR after the 4th infusion in skin, lymph nodes, and blood with good tolerability. She received an allogeneic bone marrow transplant after the 5th cycle and continues disease-free after 100 days post-transplant. CASE 3 A 36-year-old man presented with follicular infiltrated papules and alopecia affecting most of the body surface. Blood flow cytometric analysis showed 93% of pathological TL and positive TCR ϒ gene rearrangement. Skin biopsy was consistent with MF. Lymph nodes showed SS infiltration. Patient was diagnosed with Stage IVA2 SS (T2N3M0B2). He was treated with bexarotene and brentuximab with initial CR but disease progression after 10 cycles. Treatment with mogamulizumab was started with initial improvement but failure after 6 months. Mogamulizumab is a monoclonal antibody that selectively binds to CCR4 present on atypical TL. To date, only a series of 13 patients with CTCL treated with mogamulizumab in clinical practice has been reported, with good tolerability and CR in blood and skin. In our series 2 out of 3 patients presented an impressive CR in all aspects of the disease. One patient developed neutropenia and lymphopenia in relation to mogamulizumab, which resolved after specific treatment. This series supports the use of mogamulizumab in patients with refractory SS. Larger series are needed to evaluate the use mogamulizumab for CTCL in routine clinical practice.

26380 A case of cutaneous T-cell pseudolymphoma within a tattoo

A 53-year-old female with a history of systemic lupus erythematosus, hypertension, and diabetes mellitus type 2 presented with a 4-year history of red, pruritic nodules at the site of a tattoo originally placed 25 years prior on the right lower leg. Treatment with intralesional corticosteroids for 8 months led to improvement of the lesion and associated itch; however, the lesion recurred after discontinuation of the therapy. Physical examination revealed two 3-4 cm firm, erythematous to hyperpigmented smooth nodules confined to the red pigmented sites within the tattoo on the right lower anterior extremity. A punch biopsy demonstrated irregular epidermal acanthosis and spongiosis with exocytosis of lymphocytes into the epidermis. A diffuse dermal infiltrate of small lymphocytes with admixed plasma cells, histiocytes, and foamy giant cells was observed involving a fibrotic dermis and extending into the subcutis. A methenamine silver stain and Fite were negative. On immunohistochemical staining, the infiltrate predominantly expressed CD3+ with a few scattered CD20+ B-cells. A diagnosis of cutaneous T-cell pseudolymphoma was made. The patient was subsequently referred to plastic surgery where she underwent a full excision with split-thickness skin graft. We present this case of pseudolymphoma within a tattoo to highlight that tattoo ink is a risk factor for adverse immunological reactions including cutaneous pseudolymphoma. Pseudolymphoma is a rare benign reactive inflammatory infiltrate that often clinically and histologically mimics cutaneous lymphoma. The reaction inflammatory cell infiltrate can be predominantly T-cell or B-cell or mixed. Early recognition and skin biopsy is imperative for proper diagnosis and management.

Immunohistochemical Expression of p53 and bcl-2 in Psoriasis

Introduction: Apoptosis plays a major role in maintaining the balance between cellular proliferation and cell death in the skin. Blockage of apoptosis has been implicated as one of the contributing factors in the pathogenesis of psoriasis. P53 has a role in induction of cell cycle arrest, apoptosis as well as regulation of cell proliferation, bcl-2 is anti-apoptotic protein. Previous studies have reported controversial results relating to their expression in psoriatic skin. Aim: To evaluate the immunohistochemical expression of p53 and bcl-2 in the epidermis, basal cells and lymphocytes of psoriatic skin and compare it with the adjacent perilesional skin. Materials and Methods: This cross-sectional study was conducted in Hind Institute of Medical Sciences, Safedabad, Barabanki, Uttar Pradesh, India from June 2016 to December 2017. Fifty cases of psoriasis were included and punch skin biopsies including a small part of perilesional skin was taken. The sections were studied for the presence of immunohistochemical expression of p53 and bcl-2 using scoring systems. The perilesional part of the biopsy was used for comparing the histopathological and immunohistochemical expressions. The student t-test was used for comparison of groups using Statistical Package for the Social Sciences (SPSS) version 23.0 program and a p-value of &lt;0.05 was taken as statistically significant. Results: The age of the patients ranged from 15-68 years. Majority of the patients were males comprising 32 out of 50 cases (64%). The most common site was the extensor surfaces of limbs. The histopathological findings of psoriasis, such as acanthosis, spongiosis, suprapapillary thinning, dilated dermal vessels and dermal lymphocytic infiltrate was seen in all 50 cases of the lesional skin (100%). Dermal lymphocytic infiltrate was the most common finding in the perilesional skin and was observed in 21 cases (42%). Statistically significant immunohistochemical expression of p53 was seen chiefly in the epidermis, while bcl-2 expression was seen in the dermal lymphocytes of psoriatic (lesional) skin. Conclusion: The immunohistochemical expression of p53 in the epidermal keratinocytes of the lesional skin in psoriasis is suggested to be of wild type in response to frequent DNA damage in the actively cycling cells of epidermis. The expression of bcl-2 in the dermal lymphocytes could point towards its role in promoting the chronic inflammatory and recurrent nature of psoriatic lesions.

A case report of primary cutaneous marginal zone B-cell lymphoma with mastocytosis

A 53-year-old man presented with asymptomatic, dusky reddish nodules on his trunk, which had persisted for 7 years. Histological findings showed nodular to diffuse dermal infiltration of lymphocytes with irregular nuclei, eosinophils, plasma cells, and mast cells. CD20 revealed patch positivity. Periphery of lymphoid follicles showed BCL-2 positivity and BCL-6 positivity focally at the center. CD30 and toluidine blue staining showed positivity, and several mast cells were confirmed. The immunoglobulin heavy chain gene rearrangement result showed B-cell monoclonality. The patient’s condition was diagnosed as cutaneous marginal zone B-cell lymphoma, plasmacytoid type with mastocytosis. Primary cutaneous marginal zone B-cell lymphoma is an indolent lymphoma with a tendency for local recurrence. In the specimen obtained from our patient, multiple mast cells were observed. Primary cutaneous marginal zone B-cell lymphoma with prominent mastocytosis is rare and there are a few reported cases. Therefore, this case is worth reporting for its rarity and for the purpose of reminding mastocytosis in primary cutaneous marginal zone B-cell lymphoma.

Interstitial mycosis fungoides

ABSTRACT Interstitial mycosis fungoides (IMF) is a rare variant of mycosis fungoides, a cutaneous T-cell non-Hodgkin’s lymphoma. It is characterized by an interstitial dermal infiltrate of lymphocytes and histiocytes between collagen bundles. We report the case of a 54-year-old patient with pruritic hypochromic macules on the arms and forearms diagnosed with IMF. Special attention was given to the anatomopathological features that differentiate this entity from its differential diagnoses, such as inflammatory morphea, interstitial annular granuloma, and other variants of the mycosis fungoides itself. We also present a review of the literature on the classification of the IMF.

Distribution of CD1a-positive cells is not different between pseudolymphomatous folliculitis and primary cutaneous marginal zone lymphoma.

Pseudolymphomatous folliculitis (PLF) is a subtype of cutaneous pseudolymphoma that is recognized as an independent disease. PLF is characterized by dermal lymphocytic infiltration surrounding an irregular hyperplastic pilosebaceous unit (i.e., activated pilosebaceous unit). An interstitial distribution of CD1a-positive cells is regarded as an important feature of PLF, especially in distinguishing it from primary cutaneous marginal zone lymphoma (PCMZL), which is associated with a peripheral concentration of CD1a-positive cells. We undertook a clinicopathological investigation of PLF, with a reassessment of CD1a immunohistochemistry. We defined diagnostic criteria for PLF based on past studies and consequently identified 79 cases. In addition, we collected 32 cases of PCMZL and performed detailed clinical, pathological, and immunohistochemical investigations using antibodies to CD3, CD20, and CD1a. We found an interstitial concentration of CD1a-positive cells in 90.2% of PLF and 34.5% of PCMZL cases. The peripheral concentration of CD1a-positive cells was seen in 9.8% of PLF and 34.5% of PCMZL cases. In both diseases, CD1a-positive cells appeared in T-cell nests (88.5% in PLF and 92.9% in PCMZL) but were absent in B-cell nests (0% in both groups). All 79 cases of PLF showed activated pilosebaceous units while 22 of the 32 PCMZL cases displayed pilosebaceous units, although none of these were activated. In summary, regarding the distribution patterns of CD1a-positive cells as a diagnostic feature in distinguishing between PLF and PCMZL is somewhat inconclusive. To differentiate PLF and PCMZL, determining the presence or absence of activated pilosebaceous units is essential.