Thursday, March 30, 2006


What are your thoughts?

"Superficial and deep, nodular and diffuse lymphohistiocytic infiltrate forming follicular germinal centers consistent with atypical lymphoid hyperplasia.

NOTE : Immunostaining reveals a mixture of T-cells (CD3) and B-cells (CD-20). No clonal proliferation is seen on Kappa and Lambda staining. No CD-30 positive cells are noted. These findings are supportive of a lymphoid hyperplasia. If the clinical suspicion persists, follow-up of the patient is suggested"

Given the location, one wonders if this could be secondary to a tick bite (common in our area). See; Pediatr Dermatol. 2001 Nov-Dec;18(6):481-4.

Persistent atypical lymphocytic hyperplasia following tick bite in a child:
report of a case and review of the literature.

Hwong H, Jones D, Prieto VG, Schulz C, Duvic M.

Department of Internal Medicine Specialties, Section of Dermatology, University
of Texas-M.D. Anderson Cancer Center, Houston, Texas 77030, USA.

We report a 6-year-old girl who developed a red papule on the posterior neck at
the site of a previous tick bite. Initial biopsy was performed a year after the
bite and the specimen showed a dense lymphoid infiltrate with admixed CD30+
cells. The patient was referred to our center because of concern about the
development of a CD30+ lymphoproliferative disorder. The lesion was completely
excised. Histology showed no evidence of a clonal lymphoproliferative disorder
or Borrelia infection, but persistence of CD30+ cells. This case demonstrates
that a tick bite reaction can persist for more than 1 year and show
immunophenotypic and morphologic overlap with a CD30+ lymphoproliferative
disorder. Complete history with thorough clinical and histopathologic evaluation
is necessary to arrive at the correct diagnosis.

The patient is a 52 yo engineer who presents with a 2 month history of a 1.5 cm in diameter asymptomatic somewhat "spongy" presternal nodule surrounded on one side with macular non-blanchable erythema.
The clinical appearance is non-diagnostic. This may be an infiltrative process, possibly a malignancy. I have not seen anything like this before with the possible exception of a Merkel Cell carcinoma. Punch biopsies were taken from the nodule and the surrounding erythema.
The results should be back on April 3.

What are your thoughts?

Saturday, March 18, 2006


Presented by
Brian T. Maurer, Enfield, Connecticut

D.S. is a 72-year-old left-handed male with a three-year history of periungual inflammation coupled with periodic cracking, separation and nail loss on the 3rd, 4th and 5th fingers of the left hand. The pads of these fingers also appear erythematous and swollen with dry cracked skin.

Initially, a local dermatologist prescribed topical Lamisil without effect. A subsequent month-long course of oral griseofulvin likewise did nothing. The periungual inflammation seemed to respond to topical erythromycin; the patient reports that all symptoms subsided over the summer months, only to return with the cold autumn weather.

An amateur gardener and golfer, D.S. wears a golf glove on his left hand during summer golfing season (when the condition seems to subside). He reports that his left hand usually feels colder than the right in winter time.

With the exception of one discolored nail of the left great toe, the nails of his remaining fingers and toes appear normal; he exhibits no other form of dermatitis.

Questions: Given the history and clinical course, what is the diagnosis? Suggestions for treatment?

Tuesday, March 14, 2006

Digital Tumor

This 61 yo man presented with a 30 year history of an annoying tumor of his right index finger. It interferes with his writing in that it abuts on the area in contact with a pen or pencil. He has pared it down on numerous occasions and it has been unsuccessfully treated with cryotherapy in the past. The clinical picture is that of an acquired digital fifrokeratoma (see reference below). An excisional biopsy is scheduled.

Dupre A, Christol B, Bories M.
[Acquired fibro-keratoma. Report of 8 cases]
Ann Dermatol Venereol. 1977 Oct;104(10):611-5. [Article in French]

The acquired fibro-keratoma is a benign fibro-epithelial tumor of acquired
nature. I was set apart as a distinct entity in 1968 by Bart et al. who named it
"acquired digital fibro-keratoma". It is predominantly, although not
exclusively, located on the fingers and toes, near the phalangeal joints. The
authors report 8 personal cases and make a short general review of the disease.
The lesion is slightly prominent, well defined and surrounded by a
hyperkeratotic collar. It protrudes on the surface of the skin much like a
hernia. Histologically, it is a dermo-epidermal tumor. There is a proliferation
of connective tissue under the papillomatous, hyperacanthotic and orthokeratotic
epidermis. The mature collagen bundles, voluminous fibroblasts and numerous
enlarged capillaries are parallel to the vertical axis of the tumor. The
acquired fibrokeratoma must be differentiated from other cutaneous tumors,
particularly fibromas and Koenen's tumors. The etiology is unknown. However, it
was found in some cases that a trauma had contributed to the development of the
tumor. The only possible treatment is surgical excision.

Friday, March 10, 2006

Interesting Tumor

This 48 yo woman presented with a 2 year history of a tumor of the upper lip.
She has type III skin. The lesion in question is 6 mm in diameter.
A biopsy was done. This looks like a pigmented sclerotic basal cell.

She has a sick child and delayed her dermatology visit because she must take son to physicians often.
It's a three hour trip for him. He is 15 years old and has had polycythema rubra vera and essential thrombocythemia since age eight.