Firm Nodules Research Articles

A Review of Non-Invasive Skin Imaging in Merkel Cell Carcinoma: Diagnostic Utility and Clinical Implications.

Background/Objectives: Merkel cell carcinoma (MCC) is a rare and aggressive cutaneous neuroendocrine malignancy characterized by its propensity for rapid growth and early regional and distant metastasis. Given its potentially lethal nature, accurate and timely diagnosis of MCC is of utmost importance. This review aims to describe non-invasive imaging methods that can serve as additional tools in the examination of MCC. Methods: In this narrative review, we describe the up-to-date spectrum of non-invasive skin-imaging methods that can serve as additional tools in the examination of MCC based on the available literature. Dermoscopy might enhance the clinical diagnosis of MCC, facilitate differentiation from other benign and malignant tumors, and help optimize the treatment plan. New imaging technologies might also provide useful information at a sub-macroscopic level and support clinical diagnosis. These techniques include high-frequency ultrasound (HFUS), reflectance confocal microscopy (RCM) and optical coherence tomography (OCT). Results: Clinically, MCC typically presents as a rapidly growing, red, purple or skin-colored painless and firm nodule. Diagnosis is usually established with histopathological assessment and immunohistochemistry. However, dermoscopy and new imaging technologies might enhance the clinical diagnosis of MCC, facilitate differentiation from other benign and malignant tumors, and help optimize the treatment plan.

The diagnostic challenge of a Papillary lesion of the breast in a patient with Peutz-Jeghers syndrome

Abstract Introduction/Objective Peutz-Jeghers syndrome (PJS) is an autosomal dominant disorder with elevated risk of various neoplasms, including breast cancer. The incidence of cancer among PJS patients is estimated to be 15-fold higher than the general population. The spectrum of breast lesions in PJS varies from benign papillomas to invasive carcinomas, presenting significant diagnostic complexities. The case presented here revolves around a unique papillary lesion in a PJS patient. Methods/Case Report A 40-year-old African American female, with PJS presented with a palpable abnormality in the right subareolar region with sanguineous nipple discharge. Multiple prior biopsies revealed intraductal papillomas with no atypia. Imaging showed a 7.0 cm complex solid and cystic subareolar mass, which had increased in size by 42% within a short period. Given the rapid increase in size, malignant transformation was clinically suspected. The patient underwent bilateral mastectomy. Macroscopic examination showed a 9.0 cm tan firm subareolar nodule with solid and cystic components. Histopathology revealed areas consistent with intraductal papilloma, however, additional complexities, including epithelial and myoepithelial proliferations with mild cytologic atypia, squamous, apocrine, and sebaceous metaplasia made the diagnosis challenging. No necrosis or increased mitotic activity was identified. Immunostaining for CK5/6 and p63 highlighted the myoepithelial layer, while estrogen receptor demonstrated heterogeneous positive staining. This picture raised suspicion of adenomyoepithelioma, but there was a significant overlap with intraductal papilloma. A final diagnosis of intraductal papillary neoplasm with epithelial and focal myoepithelial atypia was rendered. Results (if a Case Study enter NA) NA Conclusion This case presented a complex diagnostic dilemma. The rapid growth of the lesion, coupled with cytological atypia, raised significant concern necessitating precise differentiation between adenomyoepithelioma and intraductal papilloma. Further research is imperative to explore the pathophysiology of breast lesions in PJS, their impact on surveillance, management, potential for malignancy, and prognosis. Investigating additional diagnostic modalities and molecular markers to aid in accurate differentiation between benign and malignant papillary neoplasms in PJS patients warrants consideration.

Nodular Fasciitis of the Buccal Mucosa with a Novel USP6 Gene Rearrangement: A Case Report and Review of the Literature.

Nodular fasciitis is a rare but benign fibroblastic proliferation that typically presents as a solitary lesion with rapid growth and variable mitotic activity. The lesions usually occur on the extremities and occasionally in the head/neck region. Involvement of the buccal mucosa is extremely rare with only few reports in the literature; in this case report, we describe a 41 year old female who presented with a 6-month history of a stable intraoral lump at the junction of the upper and lower lip. Fine needle aspiration revealed an atypical spindle cell population with plump cells. The surgical excision demonstrated a well circumscribed tan-white firm nodule. Histologic examination revealed a spindle cell proliferation that grew in short, intersecting fascicles with focal storiform architecture. The lesion had a pushing border that was not overtly infiltrative and the stroma contained focal myxoid changes giving a "tissue culture" appearance to the cells. Immunohistochemical testing showed the tumor cells were vimentin (+), SMA (+), weakly Calponin (+), and desmin (-), cytokeratin (-), AE1/AE3 (-), S100 (-), ALK (-), STAT6 (-), and beta-catenin (-). Fluorescence in-situ hybridization (FISH) revealed a USP6 gene rearrangement with an atypical probe pattern. Next generation sequencing identified a novel SPTAN1::USP6 fusion gene confirming the diagnosis of buccal nodular fasciitis. Identification of the characteristic histologic features and USP6 gene rearrangements helped support the diagnosis. A review of the literature identified 25 cases of nodular fasciitis involving the buccal mucosa. The occurrence of this tumor in an unusual location may pose difficulties for diagnosis.

Dermatopathology.

A female in fifties, presented with grouped multiple, skin-coloured asymptomatic, slowly growing nodules on right buttock for 2 years. Cutaneous examination, multiple discrete to confluent skin coloured firm subcutaneous nodules of size ranging from 1x1 cm to 4x3 cm on right buttock. Histopathological examination showed ectopic mature adipocytes in the dermis.

A Solitary Firm Nodule Over Cheek.

A Solitary Firm Nodule Over Cheek.

Dermotoscope assisted diagnosis of adolescent bullous pilomatricoma: six case reports

BackgroundPilomatricoma (PM) is a cutaneous benign neoplasm derived from the hair matrix. It clinically presents as a solitary and firm nodule overlying normal epidermis and is usually not easy to be noticed at early stage. Nevertheless, when special bullous lesion occurs in a short time or even ulcerates, preoperative diagnosis by a dermatologist is often challenging especially when the pediatric patients refuse biopsy.Case presentationWe present six bullous PM cases and particularly conduct correlation analysis on the dermotoscopy and histopathology detection data. The basic information, medical history, symptoms and lesion morphology results of the patients were also provided. We found that the incidence of bullous PM was higher in females than in males, and most patients were adolescents and the predilection location seem to be consistent in the vaccine injection site. The dermatoscopic features of bullous PM reported were luminous yellow structure below, with gray-blue homogeneous areas and branched capillary. The histological features were consistent with PM, and evident epidermis bullae were above the tumor with extraordinary dilation of lymphangion in the upper dermis. The patients described in this study were Chinese patients in Han population included 4 females and 2 males, coincidentally, they are almost teen-age, respectively are 5,11,17,19,21,22 year-old.ConclusionsThis study reported and analyzed the dermotoscopy and clinical characteristics of bullous PM, dermotoscopy may guide as a rapid and reliable technique in bullous PM diagnosis.

Scabies and Nodules in Children: An Intriguing Entity

Nodular scabies (NS) is a relatively common variant of classical scabies whose pathogenesis is unclear. It is clinically characterized by pruritic, firm nodules most commonly involving the genitalia followed by axilla and groin region. A clinical diagnosis of NS is often straightforward. NS may persist despite the administration of antiscabicidal drugs such as permethrin and ivermectin. Topical and intralesional corticosteroids form the mainstay of treatment. Postscabietic nodule is a complication that primarily occurs in patients with previous history of scabies that had been successfully treated.

Three Common Skin Infections in a Student Athlete and a Subsequent Outbreak of Methicillin-resistant Staphylococcus aureus Skin Infections in a Single Gym: a Case Report

Individuals with frequent physical contact, such as wrestlers, are at an increased risk of developing infectious diseases, including bacterial, viral, and fungal infections. Herein, we report the case of a student wrestler who developed three common skin infections and a subsequent outbreak of methicillin-resistant Staphylococcus aureus (MRSA) skin infections in a single gym. A 14-year-old male presented with a 2-week history of an edematous, painful skin lesion on the left outer ear. He responded poorly to empirical antimicrobial therapy. Examination revealed multiple crusts and oozing on the left ear helix. A solitary, erythematous firm nodule was also observed on the left posterior neck. Bacterial culture confirmed MRSA resistance to clindamycin and tetracycline. Further assessment confirmed the diagnosis of herpes labialis and tinea faciei. Within 3 weeks, six additional cases of MRSA skin infections were reported, all linked to the same wrestling gym. Most patients were effectively treated with oral cephalosporins combined with topical fluoroquinolones and occlusive dressing.

LUMPY SKIN DISEASE: AN ENCROACHING RISK IN CATTLE FARMING

Lumpy skin disease (LSD) is a vector-borne disease of cattle and water buffalo caused by the lumpy skin disease virus (LSDV) of the Capripoxvirus genus. LSD mainly affects the skin and the lymphatics of animals, and manifests as firm skin nodules, low feed intake, and a drop in milk production. Animal-to-animal contact, blood-feeding insects, animal products, stable flies, and mosquitoes can facilitate the transmission of LSD across herds and borders. The first case of LSD was reported in 1929 in Zambia. It was endemic to Africa until 1985 and later spread to Eastern Europe and Asia. The latest outbreak of LSD was reported in the Asia-Pacific region. At present, biosafety measures (control of animal movement, vectors, and animal products) are being devised by authorities to tackle LSD. Vaccines are also being developed for LSDV in recent decades. Live attenuated vaccines of both homologous and heterologous (of the Capripoxvirus genus) virus strains were utilized. A few side effects of the live vaccines were observed, such as skin nodules, low feed intake, and a drop in milk production. Inactivated LSDV vaccines were produced, showing a higher safety profile than live vaccines, yet offering only partial protection and lacks cross-protection. Recombinant LSDV vaccines are also under development; however, challenges remain in terms of the best vaccine delivery methods and antigen selection from the large poxvirus genome. Overall, mass vaccination with an effective vaccine may play a central role in the control of LSDV.

Giant cell collagenoma: Report of a rare tumor and review of literature.

Giant cell collagenoma (GCC) is a rare benign dermal fibrous tumor. Although it has many clinicopathological differential diagnoses, it is often confused with cutaneous sclerotic fibroma/storiform collagenoma (SF/SC) and dermatofibroma. The following characteristic features point to GCC's diagnosis over the latter: the presence of peculiar multinucleated giant cells, and vimentin positivity of both single and multinucleated giant cells on immunohistochemistry. Most of the reported cases have mentioned that GCC is a variant of SF/SC. We report a rare case of GCC presenting as a slow-growing solitary firm nodule over the right ankle. To the best of our knowledge, only less than ten cases have been reported, including the index case. We have also reviewed the clinicopathological features of those cases and discussed the approach to the diagnosis.

Nodular Hidradenoma of the Scalp: A Rare Case Report

Nodular hidradenoma is a rare benign tumour originating from eccrine or apocrine sweat glands. While documented cases exist in the medical literature, nodular hidradenoma of the scalp is relatively uncommon. We present a rare case of nodular hidradenoma located on the scalp to contribute to the limited knowledge regarding its clinical presentation, diagnosis, management and outcomes in this specific anatomical site. We present a case of a 45-year-old female with a nodular hidradenoma of the scalp. The patient complained of a slow growing swelling, itchy, slightly tender scalp lump over 9 years period. Clinical examination revealed a well-defined, firm nodule measuring 3.5 x 3 cms in diameter with 2 cms wide stalk. The patient underwent complete surgical excision, resulting in a favourable outcome for regular follow up to one year

Dendritic Cell Neurofibroma with Pseudorosette: An Uncharted Entity at Unusual Sites: Two Case Reports with Literature Review

Dendritic cell neurofibroma with pseudorosette (DCNP) is a novel entity of neurofibroma with sparse literature. Neurofibroma is a benign peripheral nerve sheath tumor having many known histological variants including localized, diffuse, plexiform, solitary, cellular, and atypical forms, all of which lead an indolent course. Like other forms of neurofibroma, DCNP usually is located in the dermis or deeper soft tissue or within the nerve trunk. It reveals a characteristic histomorphology of distinct multiple nodules comprising two types of cells: the outer lymphocyte like dark Type I cells (Schwann cell-like) forming pseudorosettes surrounding the inner scattered lighter and larger Type II cells (ganglion/dendritic cell-like). Although histogenesis of these two type of cells is debatable, immunopositivity for S100 suggests the neuronal origin and the fibrous pseudocapsule covering tumor nodules being immunopositive to epithelial membrane antigen (EMA) suggests perineurium. Here, we report two such cases of DCNP at two different yet unusual sites of cervical and perianal regions. Neither patient nor their family members had any features of neurofibromatosis(NF 1). Both the cases were adults, presented with firm nontender subcutaneous nodules of long duration causing pressure symptoms. Those were resected and evaluated for microscopy. Histomorphology aided by immunohistochemistry positivity for S100 and EMA confirmed DCNP. Follow up study after half an year of surgery was uneventful and Patients were found to be relieved of all symptoms. We present this unusual new variant that poses challenge for it’s close histological mimickers like cellular/epithelioid schwannoma and plexiform neuroma and yet want to emphasize the innocuous behavior of tumor that can be cured by surgical resection.

Bilateral Sacroiliitis in a Patient with Rheumatoid Arthritis: Unraveling the Rope: A Case Report

Rheumatoid arthritis (RA) and spondyloarthritis(SpA) are chronic inflammatory disorders with unique symptoms and pathologies. Misclassification of these two entities is prevalent due to overlapping clinical features and the presence of typical symptoms for both disorders. Rheumatoid nodules are one of the most common extra articular manifestations in rheumatoid arthritis, usually associated with severe disease activity. Herein, we describe a case of rheumatoid arthritis with bilateral sacroiliitis, an uncommon joint involvement of rheumatoid arthritis, and accelerated subcutaneous nodulosis after treatment with adalimumab. Introduction RA is a chronic, autoimmune disorder that primarily affects peripheral synovial joints [1]. The axial skeleton is usually spared other than the cervical spine, particularly C1 to C2 [1]. Though sacroiliitis is a paramount sign of SpA, it can be rarely observed in RA [2]. The commonest extra-articular manifestation of RA is subcutaneous nodules, which can be accelerated with RA treatments [3]. Herein, we describe a patient presented with bilateral sacroiliitis, along with the diagnostic and therapeutic challenges we surmounted. Case presentation A-45-years-old female presented with a one-year history of inflammatory arthritis of bilateral metacarpophalangeal, wrist, and ankle joints. She also had inflammatory-type back pain with buttock pain and plantar fasciitis. The Left-sided Faber test was positive. The laboratory investigations revealed elevated inflammatory markers, negative RF and HLA-B27. MRI-SI joints revealed bilateral active sacroiliitis. She was treated as SpA with NSAIDS at first, followed by subcutaneous adalimumab due to inadequate response. Though arthritis improved following adalimumab, multiple firm subcutaneous nodules occurred in the extensor surface of the elbow and hands after six-doses of adalimumab. Biopsy was compatible with rheumatoid nodule and anti-cyclic citrullinated peptide was positive. Based on the presence of rheumatoid nodules and positive anti-CCP antibodies, the patient was diagnosed with seropositive RA and bilateral sacroiliitis, an unusual joint involvement in RA. Discussion Sacroiliitis is the paramount clinical sign in SpA [2]. However, it can be seen in a wide range of disease conditions [4]. Misclassification between SpA and RA can occur due to overlapping clinical manifestations [4]. The Rheumatoid nodule is the most common cutaneous manifestation of RA and often seen in seropositive RA and more severe disease [3]. There have been case reports of accelerated subcutaneous nodulosis in patient with RA, treated with MTX, leflunomide, azathioprine, TNF alfa inhibitors and tocilizumab [3]. Though Inflammatory back pain, active sacroiliitis, and plantar fasciitis mislead the diagnosis, rheumatoid nodules and positive anti-CCP antibodies aid the classification of RA.

Herpes Zoster Granulomatous Dermatitis: A Rare but Memorable Complication

There have been reports of benign and cancerous cutaneous reactions developing at the site of resolved herpes zoster weeks to years after the acute infection. This case study describes a 71-year-old male patient with herpes zoster granulomatous dermatitis, a manifestation of postherpetic isotopic response. His medical history was significant for Graves' disease and chronic myelomonocytic leukemia. After presenting to the emergency department, he was diagnosed with herpes zoster generalisatus. Approximately two months after receiving treatment for herpes zoster, multiple firm subcutaneous nodules appeared on his neck. An excisional biopsy was performed to rule out leukemia cutis. The specimen displayed extensive dermal lymphohistiocyte infiltration, marked by central necrosis and atypical T cells. Tests for tuberculosis and leukemia were negative. At follow-up, an excisional biopsy of the recurrent neck nodules confirmed diffuse dermal infiltration and central necrosis. Based on the clinical and pathological findings, he was diagnosed with herpes zoster granulomatous dermatitis. He was administered systemic and topical steroid therapy over one month, after which the lesions and associated symptoms improved. Wolf's isotopic response refers to the occurrence of a new skin disease at the site of an already healed, unrelated skin disease. This phenomenon is frequently overlooked—especially following herpes zoster. Healthcare practitioners should know Wolf's isotopic response to ensure accurate diagnosis and avoid potential oversight of malignant diseases.

Nodular pyogranulomatous panniculitis due to Leishmania infantum infection in a domestic ferret (Mustela putorius furo)

Leishmaniosis is a vector-borne disease caused by different Leishmania species and transmitted by phlebotomine sand flies under natural conditions in Europe. Scientific information related to Leishmania infantum in dogs is extensive, where less information is available in cats and other companion animals. Recently, first clinical cases of L.infantum infection in domestic ferrrets (Mustela putorius furo) have been described. However, clinical information on leishmaniosis in this species is limited A 15-month-old male neutered domestic ferret was presented with chronic weight loss and the presence of coalescent, erythematous and firm subcutaneous nodules in the ventral abdominal subcutis. A fine-needle aspiration of these nodules was performed and the cytological examination revealed a granulomatous inflammation with the presence of macrophages contained a number of oval organisms with an eccentric nucleus and pale cytoplasm, compatible with Leishmania spp. amastigotes compatible with Leishmania spp. amastigotes. The nodules were surgically excised and histological examination showed a severe multifocal pyogranulomatous panniculitis. Specific immunohistochemistry and qPCR for L. infantum from excised nodules were positive. Additionally, L. infantum was cultured and isolated from the nodules by a fine-needle aspiration. An in-house Western Blot test for L. infantum was performed in serum sample and a positive result was obtained. This is the first reported case of nodular pyogranulomatous panniculitis due to L. infantum infection in a domestic ferret. Further studies are necessary to determine the relevance of domestic ferrets in the transmission of leishmaniosis. The description of new clinical forms of the disease is important as it can assist veterinarians in identifying these new clinical presentations.

Cutaneous mycobacteriosis in a dog

Mycobacteriosis is a skin disease caused by a bacterium of the genus Mycobacterium. Although prevalent, the infection has a difficult diagnosis, and its occurrence is underestimated in veterinary medicine. The disease presents firm, painless and non-pruritic nodules, mainly in the extremities of the body. The diagnosis can be confirmed by performing the histopathological exam in Ziehl-Nielsen stain to observe the bacilli. The purpose of this report was to describe a case of canine cutaneous mycobacteriosis in a mixed-breed dog, approximately 10 years old, with clinical signs of alopecia and hyperkeratosis in the lumbar region and pelvic area, and later developing nodules in the muzzle, ears, lips and scrotum, confirmed by histopathological examination. Antemortem diagnosis is laborious because it has a nonspecific clinical presentation, in addition to little knowledge about the pathogen. Based on the histopathology associated with the presence of acid-alcohol resistant bacilli in the macrophage cytoplasm, the diagnosis of cutaneous mycobacteriosis was established.

"Unusual Presentation of Epitheloid Dermatofibroma- Rare Case Report".

Dermatofibroma is a commonly occurring cutaneous entity usually centered within the skin's dermis. Dermatofibromas are referred to as benign fibrous histiocytomas of the skin, superficial/cutaneous benign fibrous histiocytomas, or common fibrous histiocytoma. These mesenchymal cell lesions of the dermis clinically are firm subcutaneous nodules that occur on the extremities in the vast majority of cases and may or may not be associated with overlying skin changes.A 20years old male presented to ENT OPD, at a private hospital, with complaints of a huge mass over right side of face since 15years, which was slowly growing and not associated with pain. On clinical examination, hard, non tender, lobulated cauliflower like mass located over right side of face extending from right side temporal region to upper border of mandible from superior to inferior. From anterior to posterior it was extending from lateral 1/3rd of forehead and covering lateral canthus of right eye upto right side tragus. We have taken incisional biopsy which was suggestive of dermatofibroma. Then surgery was performed with patient's consent. Excision with 1cm free margin was done. Raw area was covered with full thickness skin grafting and advancement flap. We found no recurrence till date. Dermatofibroma in the head and neck region is less common and often present a difficult differential diagnosis like Dermatofibrosarcoma protuberans, Kaposi Sarcoma, Basal cell carcinomas. The aim of case report is to represent case of dermatofibroma of epitheloid variety which is unusual in size.

Firm smooth polypoid nodule within a skin graft

Firm smooth polypoid nodule within a skin graft

Deep mycosis mimicking cutaneous squamous cell carcinoma.

Deep cutaneous mycoses (DCMs) and skin fungal infections can cause significant morbidity until diagnosed and treated. In immunocompromised people, Candida spp., Aspergillus spp., and Fusarium spp. fungi can cause these infections, but dermatophytes, especially Trichophyton rubrum and T. mentagrophytes, are the most common. Superficial erythematous lesions become firm subcutaneous nodules, ulcers, abscesses, or sinus tracts. In advanced cases, DCMs can cause osteomyelitis and bone loss. DCM included mycetoma, a chronic infectious disease of the skin, subcutaneous tissues, and bones. In some areas, it is endemic and can mimic cutaneous tuberculosis or cancerous lesions, making diagnosis difficult. Clinical presentation, radiological findings, and microbiological culture are used to diagnose with molecular methods helping in culture-negative cases. An immunocompetent farmer with a wrist lesion initially suspected as cutaneous squamous cell carcinoma was histologically diagnosed as eumycetoma, emphasizing the importance of considering deep mycoses in high-risk individuals and their heterogeneous clinical presentation.

Mucoepidermoid carcinoma showing continuity with the surface mucosa of the oral cavity: a report of 14 cases

We aimed to characterize the histology and the clinicodemographic features of mucoepidermoid carcinoma (MEC), showing continuity with the oral surface mucosa. We reviewed 138 cases of intraoral MEC to identify cases that showed continuity with the surface mucosa and compared their clinicodemographic findings with those of MECs not showing continuity. We compared the sex ratio using the 2-sample Z-test and compared the age distribution using the 2-sample Kolmogorov-Smirnov test. Of the 138 cases examined, 14 showed continuity with the surface mucosa. Their histology showed surface mucosa with an apparent transition to an infiltrating tumor with mucous, intermediate, and epidermoid tumor cells growing in solid and cystic patterns. Their clinical appearance ranged from firm submucosal nodules to erythematous to ulcerated lesions. They showed a strong female predilection (6:1) and sharply bimodal age distribution, with sharp peaks in the fourth and seventh decades. Mucoepidermoid carcinomas that show continuity have a demographic pattern distinct from that of conventional MECs, showing a striking female predilection and bimodal age distribution and suggesting a difference in etiology. Pathologists should remain aware that MEC in the oral cavity can have a histologic appearance of surface origin to reach the correct diagnosis.