Superficial Perivascular Lymphocytic Infiltrate Research Articles

Hypertrophic Lichen Planus in a 38-year-old Filipino Male: A Case Report

Abstract Hypertrophic lichen planus (HLP) is a papulosquamous eruption presenting with extremely pruritic hyperkeratotic flat-topped papules, plaques, and nodules. This is a case of 38-year-old male who presented with a 2-month history of generalized erythematous-to-hyperpigmented papules, patches, and plaques topped with white-to-gray oyster shell-like scales on a background of hyperpigmented macules and patches. There was no involvement of the conjunctival, otic, oral, and genital mucosae, and palmar and plantar aspects of the hands and feet. Dermoscopy showed reticular pearly white structures corresponding to the Wickham striae, comedo-like openings, blue-gray dots, brownish-black dots, and scales. Histopathologic examination revealed marked compact hyperkeratosis, wedge-shaped hypergranulosis, irregular saw-toothed epidermal acanthosis, scattered dyskeratotic keratinocytes, and superficial perivascular lichenoid infiltrate of lymphocytes, histiocytes, and melanophages. The patient was managed as a case of HLP. He was started on methotrexate 10 mg per week, bath psoralen photochemotherapy (PUVA) three times a week, betamethasone valerate 1mg/g cream twice a day for 2 weeks alternating with tacrolimus 0.1% ointment twice a day for another 2 weeks, 10% lactic acid, emollients, and sunscreen. After 6 months of treatment, there was almost 80% improvement of lesions and relief of pruritus.

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.

A Connexin Gene (GJB3) Mutation in a Chinese Family With Erythrokeratodermia Variabilis, Ichthyosis and Nonsyndromic Hearing Loss: Case Report and Mutations Update.

Background: Gap junctions formed by connexins are channels on cytoplasm functioning in ion recycling and homeostasis. Some members of connexin family including connexin 31 are significant components in human skin and cochlea. In clinic, mutations of connexin 31 have been revealed as the cause of a rare hereditary skin disease called erythrokeratodermia variabilis (EKV) and non-syndromic hearing loss (NSHL). Objective: To determine the underlying genetic cause of EKV, ichthyosis and NSHL in three members of a Chinese pedigree and skin histologic characteristics of the EKV patient. Methods: By performing whole exome sequencing (WES), Sanger sequencing and skin biopsy, we demonstrate a Chinese pedigree carrying a mutation of GJB3 with three patients separately diagnosed with EKV, ichthyosis and NSHL. Results: The proband, a 6-year-old Chinese girl, presented with demarcated annular red-brown plaques and hyperkeratotic scaly patches on her trunk and limbs. Her mother has ichthyosis with hyperkeratosis and geographic tongue while her younger brother had NSHL since birth. Mutation analysis revealed all of them carried a heterozygous missense mutation c.293G>A of GJB3. Skin biopsy showed many grain cells with dyskeratosis in the granular layer. Acanthosis, papillomatosis, and a mild superficial perivascular lymphocytic infiltrate were observed. Conclusion: A mutation of GJB3 associated with EKV, ichthyosis and NSHL is reported in this case. The daughter with EKV and the son with NSHL in this Chinese family inherited the mutation from their mother with ichthyosis. The variation of clinical features may involve with genetic, epigenetic and environmental factors.

Fixed drug eruption after Pfizer-BioNTech COVID-19 vaccine: A case report

Fixed drug eruption after Pfizer-BioNTech COVID-19 vaccine: A case report

Histopathologic Features of Maculopapular Drug Eruption

Background: Cutaneous adverse drug reaction (CADR) is common in both inpatient and outpatient clinical settings and has been associated with a large variety of medications. Drug reactions represent a significant burden to the healthcare system due to increased hospital stay durations and associated costs. Moreover, some of these reactions may be life-threatening. The most common clinical manifestation of a CADR is a maculopapular drug eruption (MDE). Due to its many clinical mimics and associations with a variety of histopathologic patterns, maculopapular drug eruption is difficult to definitively diagnose from both a clinical and histopathological perspective. Summary: We reviewed the clinical and histopathologic features of 327 cases of MDE from several studies in the literature and summarized characteristic histopathologic findings and their frequencies of occurrence. We found that the most common and suggestive histopathologic features of MDE were epidermal spongiosis, lymphocytic infiltrate, and occasional necrotic keratinocytes; interface change at the DEJ; superficial perivascular and interstitial lymphocytic infiltrate with or without eosinophils and neutrophils in the mid-to-deep dermis and mild papillary dermal edema; and dilation of superficial vessels. The presence of multiple histopathologic patterns within the same tissue specimen is also suggestive of MDE. This review and analysis suggest that a biopsy may improve the diagnostic accuracy by both establishing common and uncommon features associated with MDE and reviewing features that help to exclude other causes of maculopapular eruption. Key Message: Histopathologic criteria for the diagnosis of MDE, while not entirely specific, may aid in establishing a differential that includes a drug eruption. Thus, a biopsy can be a helpful diagnostic tool when MDE is suspected by demonstrating findings suggestive of MDE or by ruling out clinical mimics. However, biopsy results cannot be used in isolation as clinical-pathologic correlation is paramount in MDE.

Periorbital rash and scaly plaques in a 13-year–old boy

Periorbital rash and scaly plaques in a 13-year–old boy

Atrophic Lingual Plaque in Father-Son Duo.

Dear editor, A 24-year-old male presented with a tongue lesion present since adolescence. On examination, he had a single large, sharply demarcated, irregular, depressed plaque on the dorsum of the tongue. Blackish discoloration of the papillae within the lesion was noted. [Figure 1a]. Also, there were multiple, asymptomatic, annular plaques all over the body, slowly increasing in number and size with age. Most of these plaques had a hyperkeratotic double-edged border with a gutter in between with a thread-like margin with atrophy at the center in a few. Similar plaques were present in the buccal mucosa, hard palate, labial commissures, scrotum, glans, and penile shaft. His father also had multiple similar plaques on the tongue as the son, but the center was more atrophic and glazy [Figure 1c]. Furthermore, his father had similar lesions over the body and limbs [Figure 2].Figure 1: Shows (a) clinical picture of son showing a sharply demarcated large irregular plaque with bluish-grey papillae inside the border; (b) mucoscopy of the same lesion of the son with incomplete white peripheral keratotic tract with a double-free edge with few areas showing white radiating lines; (c) clinical picture of the father showing multiple sharply-demarcated plaques with atrophic papillae; (d) mucoscopic picture showing white peripheral keratotic tract with a double-free edge, dotted vessels in irregular distribution and clusters inside the plaque, loss of papillae with brown clods, and white lines in the centerFigure 2: Multiple large annular plaques with double-edged border of classic porokeratosis of Mibelli on back (a) and legs (b) and upper limb (c)Mucoscopy (DermLite DL4; Contact polarized; 10× magnification; ultrasound gel as interface media) of the tongue plaque of the son [Figure 1b] showed incomplete, peripheral, white, double-edged, keratotic tract with few areas showing white radiating lines and brown clods. In contrast, the father [Figure 1d] showed a white peripheral, double-edged, keratotic track with a center showing dotted vessels in irregular distribution and clusters inside the plaque, loss of papillae, brown clods, and white lines. Dermoscopy of the cutaneous lesion of both father and son showed the hyperkeratotic double-edged margin with the characteristic gutter in between and decreased skin markings at the center, which indicated a clinical diagnosis of classic porokeratosis of Mibelli (CPM). Biopsy and histopathological [Figure 3a and b] examination of the tongue lesion of the son showed moderately dense superficial perivascular patchy lichenoid lymphocytic infiltrate with focal interface vacuolar change. In a few places, the epidermis showed an invagination of the floor, which lacked a granular layer, whereas the walls showed hypergranulosis, and the center had a column of dyskeratotic and parakeratotic cells, the cornoid lamellae. It confirmed our clinical diagnosis of multifocal CPM.Figure 3: Showing histopathological findings {Hematoxylin and Eosin, 10 × (a) and 40 × (b)} – moderately dense superficial perivascular patchy lichenoid lymphocytic infiltrate with focal interface vacuolar change, the epidermis showed an invagination of the floor, which lacks granular layer, whereas the walls showed hypergranulosis, and the center had a column of dyskeratotic and parakeratotic cellsAlthough Pororkeratosis is clinically classified as localized and generalized, they are unified by a common histopathological finding of a column of parakeratotic cells with an absent granular layer at the base. Dermoscopy of cutaneous lesions helps diagnose as it accentuates the gutter as white track,[1] which is characteristic of porokeratosis, especially in CPM, as was seen in our case. Ahmed et al.[2] described 26 cases of primary genital porokeratosis in their review. Our literature search of PubMed and Google (till April 2021) and review of reported cases having mucosal porokeratosis [electronic supplement Table e-1] found 18 reports. Out of 21 cases, ten had labial lesions, nine cases had buccal mucosa lesions, and only six had lesions on their tongue (including the present report), making the tongue rarest of the three sites. Only labial porokeratosis was present in isolated form (seven cases), whereas the buccal mucosa lesions always presented with cutaneous lesions. In cases where the lesions were generalized with mucosal involvement (14 cases), buccal mucosal lesions were present in nine cases, six in the tongue, and only two on the lips, making buccal mucosa most common to be affected in generalized forms. Of these 14 cases, eight were of CPM, three each of disseminated superficial porokeratosis (DSP) and porokeratosis palmaris et plantaris disseminata (PPEPD). A total of six cases (including ours) had lingual porokeratosis. Previously, tongue plaque has been seen in two cases of CPM,[34] and one each in PPEPD,[5] and DSP.[6] Our case with widespread mucosal involvement is very rare. Furthermore, we could not find any literature describing the dermoscopic and histopathologic findings of lingual porokeratosis. The mucoscopic findings will help clinicians make outpatient-based spot diagnoses. Consent Consent for publication of the image is taken. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Supplement Table

Symmetric drug-related intertriginous and flexural exanthema: Clinicopathologic study of 19 cases and review of literature.

Symmetric drug-related intertriginous and flexural exanthema (SDRIFE) is a cutaneous drug reaction characterized by gluteal/anogenital erythema and symmetric involvement of other intertriginous location(s) without systemic signs. Clinicopathologic characterization has been limited to case reports and small series. We describe 19 new cases and review the literature to better define the clinical and histopathologic spectrum of SDRIFE. Pathology archives were searched for "SDRIFE" and "baboon syndrome." Cases meeting clinical criteria were included. Clinical and histopathologic features were recorded. Previous reports of SDRIFE with histopathologic descriptions were reviewed. Nineteen new cases were included, over half triggered by antibiotics. Six new causative medications were identified. Median onset was 7 days. Typical lesions were erythematous plaques or papules with or without scale. The most common histopathologic finding was superficial perivascular lymphocytic infiltrate followed by dermal eosinophils, spongiosis, and orthokeratosis. Basal vacuolization and apoptotic keratinocytes were less common. Interstitial histiocytes were present in almost half of our cases. Other findings included atypical lymphocytes and "flame figure." Appreciation of the range of inciting medications and clinicopathologic features in SDRIFE will improve recognition of this condition. Although many histopathologic features overlap with other common dermatitides, biopsy may assist in excluding key clinical mimics.

Histopathologic Patterns in Dermatophyte Infections

Background: Dermatophyte infections (DI) mimic a wide range of inflammatory diseases clinically and hyphae often play hide and seek on microscopy. Pathologists encounter biopsies with no clinical suspicion. In such instances, we need to recognize clues that point to the diagnosis. Aim: This study aims to describe the histopathologic patterns in DI. Materials and Methods: A total of 20 cases of DI were reviewed for various epidermal and dermal patterns. Results: Altered pattern of cornification was seen in all 20 cases (100%), the commonest being parakeratosis (75%), often in small mounds (55%), followed by compact orthokeratosis (50%). Neutrophils (65%) and crusting (55%) were seen, with sandwich sign noted in 65% cases. The reaction pattern most commonly seen was spongiosis (50%). Pustules were rare (20%). Mild superficial perivascular lymphocytic infiltrate (45%) was the commonest dermal pattern. Neutrophils (45%) and eosinophils (25%) were less frequent. Fungal hyphae were identified either within the zone of compact orthokeratosis (55%) or at the junction between two different patterns of cornification (45%). The limitations of this study are relatively small number of cases studied and lack of correlation with fungal culture, as they were not done in 90% of patients due to lack of clinical suspicion. Conclusion: Histopathologic patterns in DI are most often subtle, in the form of small mounds of parakeratosis and mild superficial perivascular dermal infiltrate, which overlap with several other skin diseases. Neutrophils and sandwich sign are not seen in almost half the cases. A careful search for fungi together with periodic acid–Schiff stain is mandatory whenever altered cornification is seen. Investigations such as potassium hydroxide preparation and cultures are not done unless there is clinical suspicion, which is absent in majority of the cases. Histopathology offers the only opportunity to establish a diagnosis in this easily curable condition.

Liposomal cytarabine and daunorubicin (CPX-351/Vyxeos)–associated distinct purpuric subtype of toxic erythema of chemotherapy: A retrospective review of 54 patients

Liposomal cytarabine and daunorubicin (CPX-351/Vyxeos)–associated distinct purpuric subtype of toxic erythema of chemotherapy: A retrospective review of 54 patients

Cutaneous manifestations associated with COVID-19 in children: A systematic review.

Cutaneous manifestation of COVID 19 in children has not yet been reviewed systematically. Hence, this review gives the clinicians a future direction to be vigilant for skin presentations during pandemics. The Pubmed database used for literature search with keywords COVID 19, children, and skin in different combinations. Articles published in English with cases of age one month to 18 years were eligible. The outcome included varied aspects of cutaneous and COVID 19 infection. The authors did not register review protocol. Of 51 publications identified, 13 studies containing 149 children met the eligibility criteria. Acrally located erythematous maculopapular lesion was the most common finding in 138 children. The researcher reported Erythema multiforme, varicella like exanthem, and Kawasaki disease like presentations in the rest of the cases. The duration of the skin lesion was 1 2 weeks in 43%. Skin biopsy done in 18 patients revealed superficial and deep perivascular and peri eccrine lymphocytic infiltrate and lymphocytic vasculitis. RT PCR was positive13.8% cases. Serological markers for HSV, parvovirus B19 analyzed across various studies, were negative, except positive mycoplasma pneumonia in 2 of 20 cases tested. Clinicopathologic analysis established chilblains like lesion in 43% cases with no confirmed etiology like cold exposure, autoimmune dysfunction, drug reaction, or viral infection. The usual cephalo caudal spread of a viral exanthem was also missing. However, a low number of discussed cases was a limitation of the study. The absence of any confirmed etiology for such cutaneous manifestations, the possibility of COVID 19, should be explored and thoroughly evaluated and isolated during such a pandemic.

Targetoid lesions in a patient with systemic lupus erythematosus

Rowell Syndrome is a rare presentation of lupus erythematosus manifesting as an eruption of erythema multiforme-like papules and plaques with immunological findings of positive rheumatoid factor, speckled antinuclear antibodies, and/or anti-Ro/La antibodies. This case highlights the unusual and highly debated presentation of Rowell Syndrome in a 66-year-old woman with newly-appearing erythematous, targetoid plaques in the setting of previously diagnosed systemic lupus erythematosus. Skin biopsy revealed histological features of full-thickness epidermal necrosis with focal sub-epidermal separation and a superficial perivascular lymphocytic infiltrate interpreted to favor Rowell Syndrome given her clinical history and presentation. Although no standard treatment exists, a prednisone taper and topical corticosteroids proved effective initially, with complete resolution at six months on mycophenolate mofetil and belimumab.

15397 Paraneoplastic dermatomyositis in a patient with an oligodendroglioma

A previously healthy 26-year-old white man presented with nausea, headache, and rash. Physical examination disclosed coalescing, erythematous to violaceous macules and patches on the eyelids, periorbital regions, cheeks, upper chest, shoulders, upper back, and posterior neck, and mild periorbital edema. Review of systems was positive for myalgias. Histopathologic examination of a shoulder lesion demonstrated vacuolar interface dermatitis and a sparse, superficial perivascular dermal lymphocytic infiltrate. Colloidal iron staining demonstrated dermal mucinosis. Based on these findings, the diagnosis of dermatomyositis was made. Labs demonstrated elevated serum creatine kinase (673 U/L); tests for rheumatoid factor, anti-nuclear antibodies, anti-SSA and anti-SSB antibodies, immunoglobulin subclasses, and a myomarker panel were within normal limits. A head MRI demonstrated a cystic mass in the right insula; stereotactic biopsy was consistent with an oligodendroglioma. He received a 60 mg oral dose of prednisone, and topical triamcinolone 0.1% and hydrocortisone 2.5% ointment. Within 10 days the rash completely resolved. He underwent a craniotomy for tumor resection several weeks after initial presentation. At follow-up four months later, he showed no recurrence of myalgias or rash. Ovarian, lung, and gastrointestinal cancers are most commonly associated with dermatomyositis in the Western world. To our knowledge, only 2 previous cases of dermatomyositis associated with an intracranial neoplasm have been reported: in a 39-year-old man following dendritic cell immunotherapy for an oligoastrocytoma and in a seven-year-old girl with a choroid plexus papilloma. Our case adds oligodendroglioma to the list of potential neoplasms to be considered when assessing a patient with dermatomyositis.

SnapshotDx Quiz: December 2020

SnapshotDx Quiz: December 2020

Clinical Cutaneous Features of Patients Infected With SARS-CoV-2 Hospitalized for Pneumonia: A Cross-sectional Study.

BackgroundSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a current pandemic worldwide. This virus can reach all organs and disturbs the immune system, leading to a cytokine storm in severe forms. We aimed to report cutaneous features among coronavirus disease 2019 (COVID-19) hospitalized patients.MethodsWe performed a cross-sectional study on 1 given day among all patients hospitalized in acute care for COVID-19 and included all patients with cutaneous features. Follow-up 48 hours later was obtained.ResultsAmong 59 adult patients hospitalized on the day of the study in an infectious diseases ward for SARS-CoV-2 infection who were confirmed by molecular assay and/or radiological findings (computed tomography scan), 40 were included. Several cutaneous manifestations were found: macular exanthema (80%), face edema (32%), livedo (13%), urticarial rash (8%), purpura (5%), oral lichenoid lesions (33%), and conjunctivitis (18%). Cutaneous biopsy was performed in 17 patients. Histological findings showed mast cell hyperplasia (100%), superficial perivascular infiltrate of lymphocytes (94%), and superficial edema (47%) consistent with capillary leak.ConclusionsVarious dermatological signs can be encountered during COVID-19. A macular rash was the most frequent. All cutaneous features could be related to a vascular leak process.

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.

S2619 A Case of Happy Feet—Hepatitis C Necrolytic Acral Erythema in a Hispanic Patient

INTRODUCTION: Necrolytic acral erythema (NAE) was first described in 1996 in Egyptian patients with hepatitis C (HCV) infection. This entity has been strongly associated with HCV as a unique cutaneous marker. In the United States there are 23 cases reported, with a prevalence of 1.7% in 2012. There are rare reports in the literature of this cutaneous finding in the Hispanic population. CASE DESCRIPTION/METHODS: Fifty-four-year old Hispanic man with medical history of hypertension, alcohol abuse and chronic HCV (genotype 2) presented to the outpatient clinic with complaints of bilateral scaly plaques in his feet. The lesions appeared 5 years ago, initially in bilateral toes and then progressed to dorsum of the feet with associated pruritus and pain on light touch. He had tried over the counter topical agents and anti-fungal therapy without improvement. On exam had scleral icterus, with distended abdomen and fluid wave presence. Patient had bilateral hyperpigmented-violaceous scaly and lichenified well-demarcated plaques in dorsal area of feet. Pertinent labs included platelet count of 66th/uL, AST 80IU/L, ALT 83IU/L, Tbili 1.4mg/dL and HCV RNA PCR 2,950,000 copies. Given non-profit outpatient clinic supplies we were unable to obtain punch biopsy. Patient was referred to gastroenterology and was prescribed oral zinc sulfate 150 mg daily for suspected NAE. The patient demonstrated response to the treatment and had resolution of symptoms. DISCUSSION: NAE is a unique cutaneous marker of HCV infection. Pathogenesis remains unclear, HCV RNA peptides and zinc dysregulation may play a role. Most of cases are consistent with distinct acral distribution, HCV positive and zinc deficiency. Symptoms include pruritus in 93% of cases, burning and pain. These lesions present from erythematous-violaceous hyperpigmented plaques to vesicles and flaccid bullae. Differential diagnosis includes other necrolytic erythema such as psoriasis, eczema, pellagra and necrolytic migratory erythema. Skin biopsy shows hyperkeratosis, acanthosis, spongiosis and superficial perivascular lymphocytic infiltrate. Treatment usually involves therapy for underlying HCV infection. However oral zinc supplementation has reported resolution of lesions. From the 23 cases reported in the US, there is only 2 cases in a Hispanic patient. This case represents the third reported Hispanic patient from the US with HCV and necrolytic acral erythema treated successfully with oral zinc. Further cases are needed to define additional treatment options for this rare entity.Figure 1.: Patient's feet showing lesions in dorsal area.Figure 2Figure 3.: Left foot showing scaly violaceous plaques.

Erythema Migrans and Interface Changes: More Than a Fortuitous Association.

The histology of erythema (chronicum) migrans (ECM) is classically described as a nonspecific perivascular infiltrate with a variable number of plasma cells and eosinophils. However, deviations from this pattern were described, such as focal interface changes or spongiosis, potentially posing a clinicopathological challenge. In this study, cases submitted with a serologically confirmed, clinically unequivocal, or highly suspicious diagnosis of ECM/Lyme disease between January 01, 2016, and September 01, 2018, were retrieved from the electronic database system and reviewed to delineate the histopathologic features of ECM. The series consisted of 14 cases. A superficial perivascular lymphocytic infiltrate was noted in all biopsies, accompanied by a deep and/or interstitial inflammatory infiltrate in 9 cases (64%). The inflammation ranged from relatively sparse to dense and prominent. At least focal interface changes were noted in 12 biopsies (86%). Eosinophils and plasma cells were noted in 7 (50%) and 10 (71%) cases, respectively. From a histologic standpoint, ECM is a protean entity and may manifest with a variable density of perivascular and/or interstitial lymphocytic infiltrate admixed with eosinophils and/or plasma cells and accompanied by focal interface dermatitis. Within the appropriate clinical context, ECM should be considered in the differential diagnosis of focal interface and/or sparse perivascular dermatitis.

Cutaneous dermatophyte invasion below the stratum corneum in an immunocompetent patient: To blame mixed creams or not?

Dermatophytes are pathogenic fungi that infect human skin, nails, and hair. Dermatophytes very rarely invade the epidermis below the stratum corneum in an immunocompetent host. Herein, we report a case of invasive cutaneous dermatophytosis in a 30-year-old immunocompetent male who had a history of intermittent mixed cream application on the lesion. Biopsy from the plaque showed neutrophilic spongiosis with superficial perivascular infiltrate of neutrophils, eosinophils, and lymphocytes. On periodic acid–Schiff staining, multiple branched septate hyphae in the stratum corneum were seen. Some of them were seen invading the stratum granulosum and upper spinous layer. On culture, Trichophyton schoenleinii species was isolated.