Friday, July 30, 2010

Atypical Lymphocytic Infiltrate

Presented by:
Ron Yaar, Boston University Skin Path and D.J. Elpern

Abstract:  50 yo man with few month history of an asymptomatic nodule on the scalp.

HPI: This 50 yo man has had a slowly enlarging tumor of the mid parietal scalp for three to four months.  No other similar lesions.  He has Type II diabetes and hypertension.  Meds: furosemide, metformin, Diovan, atenolol.

O/E: 15/6/2010  6-7 mm papule w/o diagnostic features mid-parietal
         15/7/2010 (reevaluation) 8 mm firm pink papule.  Difficult to see because covered with hair.

Clinical Photo: 

Image HE – 20x -  Dense, pandermal lymphocytic infiltrate.  Focal crush cell artifact at edges.
Image HE – 100x – A mixed population of cells.  A clear Grenz zone is present.
Image HE – 400x – Smaller lymphocytes mixed with highly pleomorphic cells.
Photos courtesy of Ron Yaar, M.D.

CD3 – Numerous T lymphocytes present.  Higher mag shows that most are smaller cells.
CD20 – Numerous B lymphocytes present.  Higher mag shows many of them correspond to the larger, pleormorphic cells.

H & E  20x
H & E 100x

H & E 400 x

CD 3  40x

CD 3 400x

CD 20  40x
CD 20  400x

Lab:  At this point we don't have any lab results. Will check on his latest CBC.

Diagnosis:  Solitary Atypical Lymphoid Infiltrate.  Benign or Malignant?

Questions:  Have you seen a similar case?  Could this be a reaction to a bite?  How would you approach this?

1. Talpur R, Duvic M.  Atypical lymphoid infiltration occurring at the site of a healed varicella zoster infection.  Clin Lymphoma. 2003 Mar;3(4):253-6.
Abstract:  Herpes zoster infection has been associated with a number of cutaneous reactions. The authors report the first case of a patient with an atypical epidermotropic lymphoid infiltrate that arose within skin previously affected by herpes varicella zoster. The differential diagnosis of such lesions and review of literature on previous cutaneous infiltrates occurring at sites of zoster infection are discussed.

Friday, July 02, 2010

Facial Excoriations in a 22 yo woman

Presented by Dr. Euan Coig
The Pass, Manitoba

Abstract:  Twenty-two yo homemaker with three to four year history of excoriations on face, arms and chest.

HPI:  This woman's chief complaint was "itching and pimples."  She grew up in a dysfunctional family ~ 100 miles from where she now lives .  Her father was an alcoholic who was physically and verbally abusive to her mother, her younger sister and herself.  She denies sexual abuse.  She was diagnosed with ADHD at age eight and has been treated for that since then with Ritalin.  The also suffers from migraines.  The patient went to college for two years and was studying sociology but ran out of money and dropped out.  She is now married with an 18 month old child and her husband is deployed in Afghanistan with the Canadian forces.

O/E:  The patient is an obese somewhat unkempt young woman. She has excoriations on her face, arms and chest.  Many (mostly atrophic) scars on arms and chest.  Back spared.  Many of the excoriations have serous crusts.


Diagnosis:  Excoriations in a young woman.  This is more serious than acne excoriee.  These type of lesions are self-inflicted but the patient is often not aware of doing this or will deny having done so. Many of these patients (who are almost always woman) have a history or abusive childhoods (physical and/or sexual).  This is a form of "self-harm" behavior.  These patients often fall into a no-man's zone between dermatology and psychiatry and prove difficult to treat.

Questions:  How would you approach a similar patient?

Special Comments:  Here are in-depth comments from two experts in this area, Drs. Anna Luise Kirkengen and Caroline Koblenzer. 

1. Shenefelt PD. Using hypnosis to facilitate resolution of psychogenic excoriations in acne excoriée.  Am J Clin Hypn. 2004 Jan;46(3):239-45.
Abstract:  Hypnotic suggestion successfully alleviated the behavioral picking aspect of acne excoriée des juenes filles in a pregnant woman who had been picking at the acne lesions on her face for 15 years. Acne excoriée is a subset of psychogenic or neurotic excoriation. Conventional topical antibiotic treatment was used to treat the acne. Compared with other treatments for uncomplicated acne excoriée, hypnosis is relatively brief and cost-effective and is non-toxic in pregnancy.

2. Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation. Clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment.  CNS Drugs. 2001;15(5):351-9.
Women's Health Research Program, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
Abstract:  Psychogenic excoriation (also called neurotic excoriation, acne excoriée, pathological or compulsive skin picking, and dermatotillomania) is characterised by excessive scratching or picking of normal skin or skin with minor surface irregularities. It is estimated to occur in 2% of dermatology clinic patients and is associated with functional impairment, medical complications (e.g. infection) or substantial distress. Psychogenic excoriation is not yet recognised in the DSM. We propose preliminary operational criteria for its diagnosis that take into account the heterogeneity of behaviour associated with psychogenic excoriation and allow for subtyping along a compulsivity-impulsivity spectrum. Psychiatric comorbidity in patients with psychogenic excoriation, particularly mood and anxiety disorders, is common. Patients with psychogenic excoriation frequently have comorbid disorders in the compulsivity-impulsivity spectrum, including obsessive-compulsive disorder, body dysmorphic disorder, substance use disorders, eating disorders, trichotillomania, kleptomania, compulsive buying, obsessive-compulsive personality disorder, and borderline personality disorder. There are few studies of the pharmacological treatment of patients with psychogenic excoriation. Case studies, open trials and small double-blind studies have demonstrated the efficacy of selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors in psychogenic excoriation. Other pharmacological treatments that have been successful in case reports include doxepin, clomipramine, naltrexone, pimozide and olanzapine. There are no controlled trials of behavioural or psychotherapeutic treatment for psychogenic excoriation. Treatments found to be effective in case reports include a behavioural technique called 'habit reversal'; a multicomponent programme consisting of self-monitoring, recording of episodes of scratching, and procedures that produce alternative responses to scratching; and an 'eclectic' psychotherapy programme with insight-oriented and behavioural components.

3. Arnold LM, McElroy SL, et. al. Characteristics of 34 adults with psychogenic excoriation.  J Clin Psychiatry. 1998 Oct;59(10):509-14.
Biological Psychiatry Program, University of Cincinnati Medical Center, Ohio 45267-0559, USA.
Abstract: BACKGROUND: Psychogenic excoriation, characterized by excessive scratching or picking of the skin, is not yet recognized as a symptom of a distinct DSM-IV disorder. The purpose of this study was to provide data regarding the demographics, phenomenology, course of illness, associated psychiatric comorbidity, and family history of subjects with psychogenic excoriation. METHOD: Thirty-four consecutive subjects were recruited from an outpatient dermatology practice and by advertisement. Subjects completed the Structured Clinical Interview for DSM-IV augmented with impulse control disorder modules, the Yale-Brown Obsessive Compulsive Scale, and a semistructured interview for family history, demographic data, and clinical features. RESULTS: Most subjects were women who described a mean age at onset of 38 years and a chronic course. Subjects excoriated multiple sites, most frequently the face. The behavior caused substantial distress and dysfunction. All 34 subjects met criteria for at least 1 comorbid psychiatric disorder, with a mood disorder the most common. Family histories were notable for depressive disorders and psychoactive substance use disorders. Most subjects experienced both mounting tension before excoriation and relief after excoriation as in impulse control disorders. A minority of subjects excoriated skin as part of obsessive-compulsive disorder. Body dysmorphic disorder with preoccupation about the skin's appearance precipitated excoriation in about a third of subjects. CONCLUSION: Psychogenic excoriation is chronic, involves multiple sites, and is associated with a high rate of psychiatric comorbidity. The behavior associated with the excoriation is heterogeneous and spans a compulsive-impulsive spectrum. Most subjects in this sample described features of an impulse control disorder.

4. Mohammad Jafferany, M.D.  Psychodermatology: A Guide to Understanding Common Psychocutaneous Disorders. Prim Care Companion J Clin Psychiatry. 2007; 9(3): 203–213.
Abstract: More than just a cosmetic disfigurement, dermatologic disorders are associated with a variety of psychopathologic problems that can affect the patient, his or her family, and society together. Increased understanding of biopsychosocial approaches and liaison among primary care physicians, psychiatrists, and dermatologists could be very useful and highly beneficial. This article is available free Full Text.