Saturday, September 26, 2015

Dermatofibroma with Monster Cells

A 72 year old man was seen with a four month history of a tumor on the left calf.

He is a light complected Caucasian with Type II skin.  The lesion is solitary, 9 mm in diameter.  It had a peculiar reddish brown color.

Clinical Photo:

Dermatoscopic Image
The lesion was excised.

Shows that this is a cellular dermatofibroma with monster cells.
Photomicrographs courtesy of Dr. Jag Bhawan.
Diagnosis:  Dermatofibroma with Monster Cells.  There are only four citations in PubMed on monster cells in dermatofibroma, and none of these is available fre online.  Thus, there are no accessible clinical or histopathological images online.  This post may be of interest to our readers.

Dermatofibroma with monster cells.

Tamada S, Ackerman AB.  Am J Dermatopathol. 1987 Oct;9(5):380-7.
Abstract: Nineteen cases of dermatofibroma associated with monster cells are reported. The term "monster" (an animal with a strange or terrifying shape, one unusually large for its kind) implies a strikingly atypical cell with an extremely large nucleus. Except for monster cells, these 19 lesions had all of the typical histopathological findings of dermatofibroma. The clinical diagnosis for 16 of these lesions was dermatofibroma (or histiocytoma). Three lesions were submitted without any clinical diagnosis. Eighteen of 19 lesions occurred on the extremities. One was on the back. Monster cells are seen in the early, histiocytic stage of dermatofibroma when lipophages and/or siderophages are usually present in large numbers. Only rarely were mitotic figures seen in dermatofibromas with monster cells, and they were neither numerous nor atypical. It is important for histopathologists to distinguish dermatofibroma with monster cells from cutaneous malignant fibrous histiocytoma and radiation sarcoma. The criteria for differentiation concern primarily the architectural pattern of the lesion rather than its cytological features.

Saturday, September 19, 2015

An Unusual Case of Scalp Ulceration

33 yo woman with six month history of extensive scalp ulceration

History: The patient is a 33-year-old unemployed cashier who presented for evaluation of facial erythema.  She has had insulin dependent diabetes since childhood but apparently, it was not treated for many years.  She is being seen at the Wound Care Clinic now for a large erosion of the scalp present for ~ six months. Other than insulin, her only medication is gabapentin for her scalp symptoms. 

She is married.  Lives with her husband and 18 cats.

EXAMINATION:  The examination shows a 33-year-old woman with a flat affect. She has some erythema on her cheeks and bridge of the nose.  A few, but not many, papules. 

She was wearing a  base-ball cap and when I asked her to remove it, I saw a 7 x 8 cm erosion on the scalp She says she has been picking on this for quite some time because it was itching and painful. 

The remainder of the exam was unremarkable other than showing poor dental hygiene.  

Pathology: Scalp: There is dense and deep dermal fibrosis with superficial fibrin deposition, and a mild to moderate superficial and deep perivascular lymphoplasmacytic infiltrate with occasional neutrophils and focal multinucleated giant cells.  These changes are consistent with chronic and impetiginized ulcer but are not specific for its etiology that could include previous traumatization (although the depth of the dermal fibrosis is unusual for a simple excoriation) or an infectious etiology.
Biopsy of face confirmed findings of rosacea.  No evidence of demodex or collagen vascular disease.

Lab:  CBC, Complete Chem profile normal.  ANA negative.  KOH prep from face failed to reveal demodex.

IMPRESSION:  This is a complex problem.  Her facial erythema will be treated with doxycycline.  Her scalp excoriation is worrisome. (A similar patient was described by Atul Gawande in the New Yorker a number of years ago (see reference).  I wonder if the 18 cats at home are significant.

Questions: Any thoughts you have will be appreciated.  It will be great if we can help this unfortunate woman.

1. Gawande A.  The Itch: Its mysterious power may be a clue to a new theory about brains and bodies.  New Yorker.  6/30/2008.  Full Free Text Online.

2. Dr. Sharquie from Baghdad sent us a recent article of his: The Major Psychodermatological Disorders in Iraq.  

3.  Cat’s Curse: A Case of Misdiagnosed Kerion
MB Mazlim, L Muthupalaniappen

Malays Fam Physician. 2012; 7(2-3): 35–38.  Free Full Text.

Abstract:  Kerion is an inflammatory type of tinea capitis which can be mistaken for bacterial infection or folliculitis as both conditions display similar clinical features. It occurs most frequently in prepubescent children and rarely in adults. We report a 26-year-old woman who presented with multiple tender inflammed nodules on her scalp. Her condition was misdiagnosed as bacterial abscess and treated with multiple courses of antibiotics without improvement. Later, her condition was re-diagnosed as kerion based on clinical appearance, history of contact with infected animal and Wood’s lamp examination. symptoms and lesions resolved completely with systemic antifungal treatment leaving residual scarring alopecia. The delay in the diagnosis and treatment of this patient resulted in permanent scarring alopecia.

4) See previous VGRD entry of a 9 yo girl with scarring alopecia. (January 2006)

5) Dr. Barry Ladiainski suggested this reference
Cervical Trophic Syndrome: A Distinct Clinical Entity?

Alison A. Fischer, MD; David M. Adelson, MD; Carlos Garcia, MD
Cutis. 2014 June;93(6):E6 - E7
Absract: Ulceration is not a typical feature of notalgia paresthetica or brachioradial pruritus; a history of self-mutilation due to underlying paresthesia is consistent with the diagnosis. This case report describes a patient with underlying spinal pathology; the authors discuss this case as a spectrum between trigeminal trophic syndrome and notalgia paresthetica whereby lesions of peripheral spinal nerves may lead to unilateral ulcerations restricted to a dermatome.

6) Trigeminal Trophic Syndrome: Report of 3 Cases Affecting the Scalp
Ranti S. Bolaji, MD; Barbara A. Burrall, MD; Daniel B. Eisen, MD. Cutis. 2013 December;92(6):291-296
Abstract: Trigeminal trophic syndrome (TTS) is a rare condition that results from a prior injury to the sensory distribution of the trigeminal nerve. Patients typically respond to the altered sensation with self-mutilation, most often of the nasal ala. We describe 3 patients with TTS who presented with self-induced ulcerations primarily involving the scalp. Two patients developed delusions of parasitosis (DOP) based on the resulting symptoms of TTS, which is a unique association. Trigeminal trophic syndrome may occur at extranasal sites and in any branch of the trigeminal nerve. The condition should be considered when ulcers are encountered in this nerve distribution. Symptoms such as formication may mimic DOP. Trigeminal trophic syndrome may be differentiated from DOP by the restriction of symptoms and ulcerations to the distribution of the trigeminal nerve.


Tuesday, September 08, 2015

Agminated Molluscum Contagiosum

Presented by Drs. Harold Blumenthal and Jerome Litt
Beachwood, Ohio

The patient is a 22 y.o. woman with a three month history of grouped papules at the left nostril and left upper lip.  They have been getting worse.  It was biopsied and treated with liquid nitrogen.  She has not been seen since.

Diagnosis:  Agminated molluscum contagiosum.


1. J. L. Bunch. Agminated Molluscum Contagiosum. Proc R Soc Med. 1918; 11(Sect Study Dis Child): 44.  Free Full Text.

2. Demitsu T, et. al. Attenuated ubiquitination of molluscum bodies in agminated mollusca contagiosa associated with malignant lymphoma. Eur Acad Dermatol Venereol. 2007 May;21(5):691-2.