Color Atlas of Differential Diagnosis in Dermatopathology

Transcription

1 Color Atlas of Differential Diagnosis in Dermatopathology

2 Color Atlas of Differential Diagnosis in Dermatopathology Loren E Clarke md Vice President of Medical Affairs Dermatology Unit Myriad Genetics, Inc/MYGN Salt Lake City, Utah, USA Jennie T Clarke md Associate Professor of Dermatology Milton S Hershey Medical Center Penn State University Hershey, Pennsylvania, USA Klaus F Helm md Professor of Dermatology and Pathology Milton S Hershey Medical Center Penn State University Hershey, Pennsylvania, USA JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi London Philadelphia Panama

3 Medical Publishers (P) Ltd Headquarters Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi , India Phone: Fax: Overseas Offices J.P. Medical Ltd Jaypee-Highlights. Jaypee Medical Inc. 83, Victoria Street, London medical publishers Inc The Bourse SW1H 0HW (UK) City of Knowledge, Bld South Independence Mall East Phone: Clayton, Panama City, Panama Suite 835, Philadelphia, PA 19106, USA Fax: Phone: Phone: Fax: Medical Publishers (P) Ltd Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B Shorakhute, Kathmandu Shaymali, Mohammadpur Nepal Dhaka-1207, Bangladesh Phone: Mobile: Website: Website: , Medical Publishers The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/ editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com Color Atlas of Differential Diagnosis in Dermatopathology First Edition: 2014 ISBN Printed at:

4 Dedicated to Katie and Kyle Ava and Alaina Loren E Clarke and Jennie T Clarke Klaus F Helm

5 Preface Color Atlas of Differential Diagnosis in Dermatopathology is based upon a simple algorithmic approach that simplifies diagnosis of dermatological diseases. This unique atlas uses pathologic findings correlated with clinical information to arrive at a precise diagnosis. The book is divided into 15 chapters based upon common histopathologic findings such as psoriasiform dermatitis, lichenoid tissue reaction, panniculitis, vasculitis, blistering skin diseases, adnexal neoplasms, and pigmented lesions. Color images illustrate the histological patterns along with clinical photographs. Criteria required to make an accurate diagnosis are listed in an easy-to-use outline form. Potential pitfalls in diagnosis are covered along with diagnostic pearls. Loren E Clarke Jennie T Clarke Klaus F Helm

6 Acknowledgments We would like to acknowledge the residents and faculty in Dermatology for help in supplying some of the clinical pictures, and we would like to thank the numerous editors at M/s Medical Publishers (P) Ltd, New Delhi, India, in helping with the manuscript.

7 Contents 1. The Normal Skin Pattern 1 Findings within Stratum Corneum 3 Findings within the Dermis 8 2. The Spongiotic and Psoriasiform Patterns 19 The Spongiotic Pattern 21 Simulators of Spongiotic Dermatitis 29 The Psoriasiform Pattern The Interface and Perivascular/Periadnexal Patterns 45 The Vacuolar Pattern 47 Interface Drug Eruption 55 The Lichenoid Pattern 58 The Pityriasiform Pattern 70 The Interface and Perivascular/Periadnexal Patterns The Blistering and Acantholytic Patterns 81 The Intraepidermal Blistering Pattern 85 The Subepidermal Blistering Pattern Follicular Processes 117 Infectious Bacterial Folliculitis 119 Majocchi s Granuloma 120 Herpes Zoster 121 Noninfectious Causes of Folliculitis 122 Alopecia The Nodular and Diffuse Dermal Infiltrative Patterns 133 The Granulomatous Pattern 135 The Palisading Granulomatous Pattern 167 The Neutrophilic/Suppurative Dermatitis Pattern 172 The Diffuse Histiocytic Dermatitis Pattern 182 The Lymphoplasmacytic Dermatitis Pattern 192 Dermal Infestations and Arthropod Bite Reactions The Vasculopathic Pattern 199 The Occlusive Vasculopathy Pattern 201 The Acute Vasculitis Pattern 208 The Fibrosing Vasculitis Pattern 216 Vasculitis with Macrophages/Granulomas Panniculitis 223 Septal Panniculitis 225 Lobular Panniculitis Lymphocytes Predominate 227 Lobular Panniculitis Neutrophils Predominate 229 Lobular Panniculitis Histiocytes Predominate 230 Noninflammatory Panniculitides Fibrosing Dermatitis 235 Diseases with Decreased Number of Fibroblasts 237 Diseases with Increased Number of Fibroblasts 241

8 xii Contents 10. The Depositional Pattern 247 Deposits of Amorphous Eosinophilic Material ( Hyaline Deposition) 249 Amyloidoses 249 Mucinous/Myxoid Deposits 254 Lichen Myxedematosus 254 Pretibial Myxedema (Localized Myxedema) 255 Other Deposits 256 Gout (and Pseudogout) 256 Calcinosis Cutis (and Osteoma Cutis) The Melanocytic Tumors 259 Cytologically Banal Melanocytes Confined to the Epidermis 262 Cytologically Atypical Melanocytes Confined to the Epidermis 268 Compound or Intradermal Neoplasms That are Cytologically Banal 272 Compound or Intradermal Neoplasms Composed of Spindled and/or Epithelioid Melanocytes: Spitz s and Reed s Nevi 290 Predominantly Dermal Tumors Composed of Pigment Synthesizing Melanocytes: The Blue Nevus Variants 293 Compound or Intradermal Neoplasms Composed of Markedly Atypical Melanocytes Epithelial Neoplasms 325 Non-Neoplastic Epidermal Proliferations 327 Benign Keratinocytic Neoplasms 331 Malignant Tumors Arising from Epidermis Adnexal Neoplasms 347 Criteria for Sebaceous Differentiation 349 Types of Sebaceous Neoplasms 349 Follicular Neoplasms 354 Follicular Neoplasms Differentiating towards Infundibulum and Isthmus 354 Tumor of Hair Matrix 360 Tumors of External Root Sheath 361 Tumors of Hair Germ 362 Tumors of Hair Mesenchyme 364 Apocrine Neoplasms 366 Criteria for Apocrine Differentiation 366 Neoplasms Exhibiting Follicular-Sebaceous Apocrine Differentiation 366 Tumors Exhibiting both Eccrine and Apocrine Variants 368 Purely Apocrine Neoplasms 371 Eccrine Neoplasms 373 Criteria for Eccrine Differentiation (Diagnosis of Exclusion) 373 Eccrine Neoplasms 373 Cysts The Mesenchymal Tumors 381 Paucicellular or Patternless Tumors 383 The Fascicular and Storiform Tumors 399 The Myxoid Tumors 423 The Epithelioid Tumors 434 The Lipomatous Tumors 444 The Vascular Tumors 451 The Pleomorphic Tumors 472 The Histiocytoid Tumors 475 The Round Cell Tumors The Cutaneous Hematolymphoid Neoplasms 481 The Epidermotropic/Adnexotropic Pattern 483 The Dermal ± Subcutaneous Pattern 492 The Subcutaneous Pattern 509 Index 511

9 CHAPTER 8 Panniculitis

10 INTRODUCTION Panniculitis can be subdivided into primarily lobular and primarily septal panniculitis. A primarily septal panniculitis is usually erythema nodosum. The septae can be involved in vasculitis and other dermal inflammatory processes can extend SEPTAL PANNICULITIS into the septae, such as morphea/scleroderma and necrobiosis lipoidica, but the primary septal panniculitis remains erythema nodosum. The differential diagnosis for lobular panniculitis is somewhat more extensive and can primarily be distinguished by examining the predominant cell type. 225 Panniculitis Erythema Nodosum (Figs 8.1A to E) Clinical diagnosis Subcutaneous red to violaceous nodules overlying shins. Criteria for diagnosis Early lesion (Fig. 8.1A) Hemorrhage Edema within septae Neutrophils within septae Established lesion (Figs 8.1B and C) Fibrotic septae Granulomatous inflammation Miescher s radial granuloma (histiocytes and giant cells surrounding a cleft) (Fig. 8.1D). Differential diagnosis Lipodermatosclerosis Vasculitis Factitial Erythema induratum Scleroderma. Pitfalls The granulomatous inflammation in necrobiosis lipoidica can spill over into the septae. Pearls Erythema nodosum never ulcerates Panniculitis below the knees is erythema nodosum until proven otherwise Erythema nodosum can be chronic (erythema nodosum migrans, subacute migratory panniculitis of Vilanoma). A B Figs 8.1A and B

11 226 Color Atlas of Differential Diagnosis of Dermatopathology C E D Figs 8.1A to E: Erythema Nodosum. (A) Early lesion: edema and mixed inflammatory infiltrate in septae and surrounding fat lobule; (B) Old lesion: fibrosis with giant cells in septae; (C) Fibrosis and giant cells in septae; (D) Miescher s granuloma: histiocytes surrounding cleft; (E) Clinical picture. Courtesy: Dr Christie Regula.

12 LOBULAR PANNICULITIS LYMPHOCYTES PREDOMINATE 227 Differential Diagnosis of Lobular Lymphocytic Panniculitis Subcutaneous T-cell lymphoma Lupus/connective tissue panniculitis Cold panniculitis. Panniculitis Subcutaneous T-Cell Lymphoma (Figs 8.2A to C) Criteria for diagnosis Atypical lymphocytes. A Pearls Two forms of subcutaneous T-cell lymphoma: Alpha beta type: protracted course Gamma/delta T-cell phenotype: rapidly fatal. B C Figs 8.2A to C: Subcutaneous T-cell lymphoma. (A) Lobular lymphocytic panniculitis; (B) Atypical lymphocytes; (C) Atypical lymphocytes producing rim/circle around adipocyte.

13 228 Color Atlas of Differential Diagnosis of Dermatopathology Lupus Panniculitis (Figs 8.3A to D) A Criteria for diagnosis Lobular lymphocytic panniculitis with no atypical lymphocytes (Fig. 8.3A) Also look for: Hyaline fat necrosis (Figs 8.3B and C) Occasional calcification Lymphocytic dust. Pitfalls Missing the diagnosis of subcutaneous T-cell lymphoma (see prior). Pearls The epidermal and dermal findings of lupus erythematosus are only present in approximately half of the cases. B C Figs 8.3A to D: Lupus panniculitis. (A) Lobular lymphocytic panniculitis with lymphoid aggregates; (B) Hyalin fat necrosis; (C) Hyalin fat necrosis with lymphoid aggregates; (D) Clinical picture. D

14 LOBULAR PANNICULITIS NEUTROPHILS PREDOMINATE 229 Differential Diagnosis of Neutrophilic Panniculitis Pancreatic fat necrosis Infectious panniculitis Alpha one antitrypsin deficiency Subcutaneous Sweet s syndrome Pyoderma gangrenosum. Pancreatic Panniculitis A Criteria for diagnosis Neutrophilic panniculitis (Fig. 8.4A) Fat necrosis Ghost cells (Fig. 8.4B) Calcification Confirm presence of pancreatitis with serum amylase. Infectious Panniculitis B Criteria for diagnosis Special stains for infectious organisms positive. Alpha One Antitrypsin Deficiency Criteria for diagnosis Neutrophilic lobular panniculitis with focal areas of fat involvement Confirm with blood study for alpha one antitrypsin level. Panniculitis Figs 8.4A and B: Pancreatic panniculitis. (A) Necrosis with neutrophilic infiltrate; (B) Ghost cells, neutrophilic infiltrate and necrosis.

15 230 LOBULAR PANNICULITIS HISTIOCYTES PREDOMINATE Color Atlas of Differential Diagnosis of Dermatopathology Differential Diagnosis of Lobular Histiocytic Panniculitis Erythema induratum Erythema nodosum (spill over from septae) Factitial panniculitis Inflammatory infiltrate polymorphous and does not fit any established category Usually asymmetric and involves opposite extremity of patients dominant hand Infection Sarcoidosis or foreign object. Infectious Panniculitis Criteria for diagnosis Special stains or culture demonstrate infectious organisms. A Erythema Induratum/Nodular Vasculitis (Figs 8.5A and B) Clinical criteria for diagnosis Panniculitis frequently involving the calf with ulceration. Histological criteria for diagnosis Lobular panniculitis with mixed inflammatory infiltrate histiocytes usually predominate (Fig. 8.5B). Associated with tuberculosis Frequent vasculitis of small or medium sized blood vessels Frequent necrosis Clinically, predilection for calf Lesions ulcerate. Figs 8.5A and B: Erythema induratum. (A) Lobular lymphohistiocytic panniculitis; (B) Lobular panniculitis with histiocytes and giant cells. B

16 Subcutaneous Fat Necrosis of Newborn (Figs 8.6A to D) 231 A Clinical criteria for diagnosis Indurated plaque or plaques in newborn baby Frequently located on cheeks, trunk, buttocks and thighs History of exposure to cold during delivery or birth. Histologic criteria for diagnosis Lobular panniculitis with histiocytes Cleft like spaces in fat (Fig. 8.6C) Newborn baby. B Differential diagnosis Sclerema neonatorum: No inflammation Post steroid panniculitis: Older child. Panniculitis C Figs 8.6A to D: Subcutaneous fat necrosis of newborn. (A) Lobular panniculitis; (B) Sparse lymphohistiocytic infiltrate; (C) Needle like clefts within adipocytes; (D) Extensive subcutaneous fat necrosis of newborn. D

17 232 NONINFLAMMATORY PANNICULITIDES Calciphylaxis (Figs 8.7A to C) Color Atlas of Differential Diagnosis of Dermatopathology Criteria for diagnosis Calcified blood vessels within subcutaneous septae (Fig. 8.7B) Extravascular calcification Majority of cases patients have renal disease Increased parathyroid hormone levels Ulcer may be present. A Differential diagnosis Arteriosclerosis (Buerger s disease). B C Figs 8.7A to C: Calciphylaxis. (A) Minimal inflammatory infiltrate; (B) Calcified blood vessel; (C) Calcification and sparse inflamatory infiltrate in fat septae.

18 Lipodermatosclerosis (Figs 8.8A to C) Criteria for diagnosis Adipocytes vary in size and shape Few foam cells Minimal inflammation Cystic areas sometimes present (lined by hyalin like material from necrotic fat-imparting membranous appearance). Differential diagnosis Traumatic fat necrosis. Pitfalls Lipomembranous changes as seen in lipodermatosclerosis can be seen as sequelae of other panniculitides. Pearls Diffuse involvement of lower leg often with fibrotic thickened fat septae in lipodermatosclerosis Traumatic fat necrosis usually localized occasionally encapsulated. 233 Panniculitis A B C Figs 8.8A to C: Lipodermatosclerosis. (A) Fibrosis, minimal inflammation and fat cells with variation in size; (B) Small cystic areas within fat lobules with variation in size of adipocytes; (C) Clinical picture.

19 234 Color Atlas of Differential Diagnosis of Dermatopathology BIBLIOGRAPHY 1. Delgado-Jimenez Y, Fraga J, Garcia-Diez A. Infective panniculitis. Dermatol Clin. 2008;26(4): Fraga J, Garcia-Diez A. Lupus erythematosus panniculitis. Dermatol Clin. 2008; 26(4): Garcia-Romero D, Vanaclocha F. Pancreatic panniculitis. Dermatol Clin. 2008; 26(4): Guhl G, Garcia-Diez A. Subcutaneous sweet syndrome. Dermatol Clin. 2008;26(4): Kao GF, Resh B, McMahon C, et al. Fatal subcutaneous panniculitis-like T-cell lymphoma gamma/delta subtype (cutaneous gamma/delta T-cell lymphoma): report of a case and review of the literature. Am J Dermatopathol. 2008;30(6): Mascaro JM. Jr, Baselga E. Erythema induratum of bazin. Dermatol Clin. 2008;26(4): Mitra S, Dove J, Somisetty SK. Subcutaneous fat necrosis in newborn-an unusual case and review of literature. Eur J Pediatr. 2011;170(9): Morrison LK, Rapini R, Willison CB, et al. Infection and panniculitis. Dermatol Ther. 2010;23(4): Parveen Z, Thompson K. Subcutaneous panniculitis-like T-cell lymphoma: redefinition of diagnostic criteria in the recent World Health Organization-European Organization for Research and Treatment of Cancer classification for cutaneous lymphomas. Arch Pathol Lab Med. 2009;133(2): Polcari IC, Stein SL. Panniculitis in childhood. Dermatol Ther. 2010;23(4): Requena L, Yus ES. Erythema nodosum. Dermatol Clin. 2008;26(4): Requena L, Yus ES. Panniculitis. Part I. Mostly septal panniculitis. J Am Acad Dermatol. 2001;45(2): Requena L, Yus ES. Panniculitis. Part II. Mostly lobular panniculitis. J Am Acad Dermatol. 2001;45(3): Sanmartin O, Requena C, Requena L. Factitial panniculitis. Dermatol Clin. 2008;26(4): Valverde R, Rosales B, Ortiz-de Frutos FJ, et al. Alpha-1- antitrypsin deficiency panniculitis. Dermatol Clin. 2008;26(4):