Napa Valley Dermatopathology Meeting 2018 - Select Infections & Infestations Whitney A. High, MD, JD, MEng whitney.high@ucdenver.edu Professor of Dermatology & Pathology Vice-Chairman, Dermatology Director of Dermatopathology Director of Adult Dermatology Clinic University of Colorado School of Medicine May 17, 2018 Napa, CA Viral Infections Chicken Pox Varicella zoster virus Clinical often children crops of lesions centripetal accentuation R/O folliculitis vs. PLEVA 1
Epidermal Necrosis Vesiculation Multinucleated Keratinocytes Acantholysis with Cytopathic Effect Eosinophilic Intranuclear Inclusions 2
Zoster VZV IHC Case 24 year old EKG tech Seen at PCP for odd rash 72 hour h/o scattered lesions on all body Had vaccinations for VZV 1994 and 2009 3
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Tip: VZV (and sometimes HSV) may be very folliculocentric in nature Tip: viral infections can be confused with lymphomas 6
Unusual Case 46 y/o HIV(+) male Painful genital ulcer Enlarging x 12 months Failed 6 courses of ACV Off HAART x 2 months Two prior HSV cultures by ID were negative Initial Histological Assessment Assessed in Pathology Department Bug stains negative CD3 CD20 CD79 BCl-2 Kappa Lambda No specific diagnosis rendered. Worrisome for plasmacytoid lymphoma. Will consult with ****. **** also believed it was worrisome for lymphoma, but not diagnostic. Histology 10x 7
Histology 20x 40x CD20 Stain 8
HSV Stain 10x 20x 40x PCR (+) HSV II Cx (+) ACV resistant strain Diagnosis: Acyclovir resistant HSV II infection Bacterial Infections 76 year-old man Fremont County, Colorado rash x years 9
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AFB Fite This is all the same infection This is still all the same infection 12
Tip: There is one disease that can be included in almost any inflammatory differential diagnosis - Syphilis! Secondary Syphilis Superficial & Deep with Plasma Cells Copious Plasma Cells This is syphilis Lichenoid and slightly psoriasiform 13
This is syphilis also 19 cases of secondary syphilis superficial and deep perivascular pattern (9) lichenoid pattern (4) combined pattern (6) Plasma cells were sparse in 4 cases Granulomas in 53% of cases Papillary edema and plump endothelial cells common Perineural infiltrate was seen in 74% of cases Variable acanthosis and dyskeratosis in the epidermis Secondary Syphilis Immunohistochemical Studies 14
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Tip: If syphilis is a possibility, always recommended serologic testing. Fungal Infections 17
R/O PG Tip: Awareness of PG has increased remarkably, and that is great, but it is still a rule out diagnosis. 18
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R/O PG In my clinic. Certainly has some unusual features of PG 20
Tip: KOH Prep It works! Second Biopsy 21
Blastomycosis Caused by dimorphic fungus - Blastomyces dermatitidis Associated with hunting, forestry, excavation, fishing gardening and trapping Lungs, skin, bones often affected Acute disease can be fulminant 68% of patients presenting with ARDS #1 treatment itraconazole 22
Protozoal Infections Unusual Case 53 year old CU professor SCC of the ear Mohs After surgery: persistent inflammation, warmth swelling Post surgical chondritis? Serous, hemorrhagic and inflammatory crusting Ulcer Continued inflammatory infiltrate in the dermis 23
Russell body Mott cell Mostly lymphocytes, histiocytes, plasma cells Look here! Minute dots getting even larger yet, among the otherwise chronic inflammation Case 29 year old woman Yoga instructor Recent travel to Costa Rica Recent outside dx of SCC Sent to Mohs surgeon 24
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CDC Results (free of charge) 26
Tip: BE CAREFUL - Leishmaniasis can cause features that mimic SCC and too few clinicians provide a history that would actually increase suspicion. Nematode Infection Case 52 year-old man from Lima Migratory urticarial plaques Family of money and influence Eats ceviche twice/week 27
Gnathostomiasis Fish nematode - Gnathostoma spinigerum Emerging pathogen Formerly of Thailand, now in Mexico & Peru Can cause of eosinophilic meningitis Anisakis more common illness from sushi (but requires a inept chef) What has been will be again, what has been done will be done again; there is nothing new under the sun. - Eccl. 1:9 28
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Tip: Don t eat raw fish! Infestations Scabies Sarcoptes scabiei var hominis Arachnid (8 legs) Ubiquitous First visualized in 1687 in Italy Often occurs in 30 year epidemics Last epidemic from 1960 s still continuing 30
Wrist area Scabies Clinical Penile Nodules 31
Real world results of a good scabies prep Scabies Crusted Variant (HIV patient) 32
The Scourge Cimex lectularius bed bug bedbug A true insect 6 legs Life cycle requires a blood meal to molt 5-7 mm Armed Forces Pest Management Board Image Database (Public Domain) 33
The Bites Superficial and deep perivascular dermatitis with eosinophils. Thank you. 34