Cincinnati 01-26 2nd Ed.
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Transcript of Cincinnati 01-26 2nd Ed.
Cincinnati PathCincinnati Path1-261-26
Pamela Norden, MDPamela Norden, MD
01/200601/2006
22ndnd Edition 01/2007 Edition 01/2007 O. Aspen, MDO. Aspen, MD
1.1. Accessory TragusAccessory Tragus
Accessory TragusAccessory Tragus
Polypoid LesionPolypoid Lesion Central focus of superficial fatCentral focus of superficial fat Occassional Central Focus of Occassional Central Focus of
CartilageCartilage Multiple Small Vellus Hairs evenly Multiple Small Vellus Hairs evenly
placedplaced
2.2. Acquired Digital Acquired Digital FibrokeratomaFibrokeratoma
Acquired Digital Acquired Digital FibrokeratomaFibrokeratoma
Acral PolypoidAcral Polypoid Hyperkeratosis, Hypergranulosis, Hyperkeratosis, Hypergranulosis,
AcanthosisAcanthosis Elongated Rete RidgesElongated Rete Ridges Small ectatic vessels in dermal Small ectatic vessels in dermal
papillaepapillae Fibrous stroma with longitudinally Fibrous stroma with longitudinally
oriented collagenoriented collagen
Acquired Digital Acquired Digital FibrokeratomaFibrokeratoma
No neural tissueNo neural tissue No mixoid tissueNo mixoid tissue No koilocytesNo koilocytes
Differential DiagnosisDifferential Diagnosis
WartWart Accessory DigitAccessory Digit Traumatic AmputationTraumatic Amputation Infantile Digital FibromaInfantile Digital Fibroma
3.3. Supernumerary NippleSupernumerary Nipple
Supernumerary NippleSupernumerary Nipple
Mild irregular epidermal hyperplasia Mild irregular epidermal hyperplasia with elongation and broadening of with elongation and broadening of the rete ridgesthe rete ridges
Sebaceous hyperplasiaSebaceous hyperplasia Increased dermal smooth muscleIncreased dermal smooth muscle
May see May see lactiferous lactiferous ducts with ducts with stratified stratified cuboidal cuboidal epitheliumepithelium
4.4. Epidermolytic Epidermolytic HyperkeratosisHyperkeratosis
Clear Spaces in the Granular and Spinous Layers
Epidermolytic Epidermolytic HyperkeratosisHyperkeratosis
Increased granular cell layerIncreased granular cell layer Like a wart but with a higher dropout of Like a wart but with a higher dropout of
nuclei (most cells without nuclei)nuclei (most cells without nuclei) Moth-eaten/FrothyMoth-eaten/Frothy
Cell membranes “falling apart”Cell membranes “falling apart” Stippling of keratohyalin granulesStippling of keratohyalin granules
Differential DiagnosisDifferential Diagnosis
WartWart Benign keratosisBenign keratosis Epidermal neviEpidermal nevi
5.5. Verruca PlanaVerruca Plana
Verruca PlanaVerruca Plana
Hyperkeratosis with epidermal hyperplasiaHyperkeratosis with epidermal hyperplasia Increased granular cell layerIncreased granular cell layer Koilocytes =Owl’s eyes (bunched in 2s)Koilocytes =Owl’s eyes (bunched in 2s)
Clear around nucleusClear around nucleus Vs. Pagets which has perinuclear mucinous Vs. Pagets which has perinuclear mucinous
stromastroma VP involves the upper 1/3 of the epidermisVP involves the upper 1/3 of the epidermis
KoilocytesKoilocytes
Vacuolated cells withVacuolated cells with
Clumped keratohyaline Clumped keratohyaline
Granules and small Granules and small
deeply basophilic nucleideeply basophilic nuclei
Surrounded by a clear Surrounded by a clear
halohalo
6.6. Bowen’s DiseaseBowen’s Disease
Bowen’s DiseaseBowen’s Disease
Every cell in the epidermis is atypicalEvery cell in the epidermis is atypical Dyskeratotic cells in the epidermis Dyskeratotic cells in the epidermis
can be vacuolated with clear haloscan be vacuolated with clear halos Paler in the upper epidermisPaler in the upper epidermis
DDxDDx
Verruca Plana (but Bowen’s has Verruca Plana (but Bowen’s has dyskeratotic cells)dyskeratotic cells)
Paget’s Disease (but Paget’s lacks Paget’s Disease (but Paget’s lacks dyskeratotic cells and Paget’s cells dyskeratotic cells and Paget’s cells are not clear)are not clear)
Paget’sPaget’s
7.7. Tinea VersicolorTinea Versicolor
Tinea VersicolorTinea Versicolor
Invisible Dermatosis at low powerInvisible Dermatosis at low power Mild inflammation on high powerMild inflammation on high power Differs from dermatophyte because Differs from dermatophyte because
you can see TV well on H&Eyou can see TV well on H&E You need to see both spaghetti and You need to see both spaghetti and
meatballsmeatballs
H & E
PAS Stain
DDx for Invisible DermatosisDDx for Invisible Dermatosis
Tinea VersicolorTinea Versicolor Ichthyosis Vulgaris (has no granular Ichthyosis Vulgaris (has no granular
layer)layer) Macular Amyloid (slight pigment Macular Amyloid (slight pigment
incontinence)incontinence) TMEPTMEP ArgyriaArgyria UrticariaUrticaria
8.8. Acanthosis NigricansAcanthosis Nigricans
Acanthosis NigricansAcanthosis Nigricans
Most striking feature is PapillomatosisMost striking feature is Papillomatosis Hyperkeratosis often most evidence in Hyperkeratosis often most evidence in
between church spires (but may be uniform)between church spires (but may be uniform) Acanthosis usually not seen but may be Acanthosis usually not seen but may be
presentpresent Hard to distinguish from epidermal nevusHard to distinguish from epidermal nevus No inflammationNo inflammation May see TV spores in the stratum corneumMay see TV spores in the stratum corneum
DDxDDx
Epidermal Nevus (Hard to Epidermal Nevus (Hard to distinguish)distinguish)
Confluent and Reticulated Confluent and Reticulated PapillomatosisPapillomatosis
99 Porphyria Cutanea Porphyria Cutanea TardaTarda
Porphyria Cutanea TardaPorphyria Cutanea Tarda
Cell poor subepidermal blisterCell poor subepidermal blister Festooning (NOT specific for PCT)Festooning (NOT specific for PCT) Inflammatory cellsInflammatory cells
Lymphs only = PCTLymphs only = PCT Eos and Neuts = BP vs EBAEos and Neuts = BP vs EBA
Acral SkinAcral Skin
Hyaline Thickening of Blood Vessels (rare in PCT common in EPP)
PAS Stain
Caterpillar Bodies, only mentioned in Bhawan CD
DDx for Subepidermal DDx for Subepidermal BlisterBlister
CELL POORCELL POOR CommonCommon
PCTPCT EBEB BPBP
RareRare SuctionSuction Renal FailureRenal Failure Coma/FrictionComa/Friction AmyloidAmyloid DiabetesDiabetes
NOT CELL POORNOT CELL POOR DHDH Linear IgALinear IgA Bullous LupusBullous Lupus BP/HG/CPBP/HG/CP EBAEBA Bullous ScabiesBullous Scabies Bullous MastocytosisBullous Mastocytosis
10.10.Bullous PemphigoidBullous Pemphigoid
PemphigoidPemphigoid
Cell rich subepidermal blisterCell rich subepidermal blister +/- festooning+/- festooning 75% eos and 25% neuts (vs. EBA 75% eos and 25% neuts (vs. EBA
with reverse)with reverse)
PearlsPearls
Look at the papilla to make sure Look at the papilla to make sure there are no neuts there before there are no neuts there before putting EBA or BP as DH can also putting EBA or BP as DH can also have large blisters (and a few eos)have large blisters (and a few eos)
Bullous EM has lymphocytes, no eos Bullous EM has lymphocytes, no eos or neuts and will have epidermal or neuts and will have epidermal necrosisnecrosis
11.11.Erythema MultiformeErythema Multiforme
Erythema MultiformeErythema Multiforme
Classical superficial infiltrate but may Classical superficial infiltrate but may go deepergo deeper
Normal stratum corneumNormal stratum corneum Necrotic Keratinocytes at different Necrotic Keratinocytes at different
levelslevels +/- spongiosis+/- spongiosis Lymphocytic infiltrateLymphocytic infiltrate
DDxDDx
PLEVA (EM has a normal stratum PLEVA (EM has a normal stratum corneum and PLEVA has parakeratosis corneum and PLEVA has parakeratosis and deeper dermal involvement)and deeper dermal involvement)
Lichen Planus (only has necrotic Lichen Planus (only has necrotic keratinocytes at the basal layer vs. EM)keratinocytes at the basal layer vs. EM)
Acute Fixed drug (eos and neuts instead Acute Fixed drug (eos and neuts instead of EM which has lymphs)of EM which has lymphs)
12.12.Graft Versus Host Graft Versus Host DiseaseDisease
GVHDGVHD
Can be variableCan be variable Early = necrotic keratinocytesEarly = necrotic keratinocytes Necrotic cells are also periadnexal Necrotic cells are also periadnexal
(vs. EM)(vs. EM) Mild infiltrateMild infiltrate
Vacuolar Alteration of Basal Cells; mild papillary dermal lymphocytic infiltrate
DDxDDx
EM (necrotic cells don’t go down EM (necrotic cells don’t go down adnexa)adnexa)
Drug rash (has eos)Drug rash (has eos)
13.13.Coma BlisterComa Blister
Coma BlisterComa Blister
Intra and subepidermal blisterIntra and subepidermal blister Necrotic sweat gland epitheliumNecrotic sweat gland epithelium
All red from the hypoxia almost look like All red from the hypoxia almost look like vesselsvessels
Looks like EM of the sweat glandLooks like EM of the sweat gland Minimal inflammatory cellsMinimal inflammatory cells
14.14.Incontinentia PigmentiIncontinentia Pigmenti
Incontinentia PigmentiIncontinentia Pigmenti
Eosinophilic SpongiosisEosinophilic Spongiosis Dyskeratotic Cells/Necrotic Dyskeratotic Cells/Necrotic
KeratinocytesKeratinocytes Pigment incontinence (hence the Pigment incontinence (hence the
name)name)
Stage OneStage One
Stage TwoStage Two
DDx for Eosinophilic DDx for Eosinophilic SpongiosisSpongiosis
PemphigusPemphigus PemphigoidPemphigoid Drug EruptionDrug Eruption Contact DermatitisContact Dermatitis Arthropod BiteArthropod Bite IPIP Erythema Toxicum Neonatorum ( more of Erythema Toxicum Neonatorum ( more of
an abscess)an abscess)
15.15.Acute Fixed Drug Acute Fixed Drug ReactionReaction
Acute Fixed Drug EruptionAcute Fixed Drug Eruption
Normal Stratum CorneumNormal Stratum Corneum Necrotic Keratinocytes at all levelsNecrotic Keratinocytes at all levels Vacuolar Degeneration of the Basal Vacuolar Degeneration of the Basal
LayerLayer Pigment IncontinencePigment Incontinence
*Before answering EM look for eos and *Before answering EM look for eos and neuts. If you find them, think acute neuts. If you find them, think acute fixed drugfixed drug
16: Toxic Epidermal 16: Toxic Epidermal NecrolysisNecrolysis
TENTEN
Confluent wipe-out of epitheliumConfluent wipe-out of epithelium Full thickness necrosisFull thickness necrosis Often little inflammationOften little inflammation * EM is not confluent* EM is not confluent
17.17.Dermatitis Dermatitis HerpetiformisHerpetiformis
DHDH
Subepidermal inflammatory blistersSubepidermal inflammatory blisters Intense neutrophilic infiltrate in the Intense neutrophilic infiltrate in the
papillary dermispapillary dermis Neutrophilic Microabscesses in Neutrophilic Microabscesses in
dermal papillaedermal papillae
Granular IgA deposition in the Papillary Dermis
DDxDDx
Sweet’s Syndrome- Usually edema Sweet’s Syndrome- Usually edema no definite blisterno definite blister
VasculitisVasculitis Bullous Lupus (put this if DH is not a Bullous Lupus (put this if DH is not a
choice)choice) Linear IgALinear IgA
18.18.Darier’s DiseaseDarier’s Disease
Darier’s DiseaseDarier’s Disease
Papillomatous Epidermal HyperplasiaPapillomatous Epidermal Hyperplasia Dyskeratosis starting suprabasally but Dyskeratosis starting suprabasally but
can involve any surfacecan involve any surface ““Dry” –No spongiosisDry” –No spongiosis Corp ronds = swollen cells with halos Corp ronds = swollen cells with halos
located only in the granular layerlocated only in the granular layer Grains are found in the stratum Grains are found in the stratum
corneumcorneum
DDxDDx
Grovers (in general has 2 types of Grovers (in general has 2 types of acantholytic processes on biopsy, acantholytic processes on biopsy, spongiosis and acanthosisspongiosis and acanthosis
Warty dyskeratoma (cup shaped)Warty dyskeratoma (cup shaped)
19: Herpes Simplex19: Herpes Simplex
Herpes SimplexHerpes Simplex
Acantholytic cells with Acantholytic cells with multinucleated giant cellsmultinucleated giant cells
Steel grey nucleusSteel grey nucleus Intraepidermal blisterIntraepidermal blister
BallooningDegeneration Multinucleated
Giant Cell? Steel grey nucleus
20.20.Warty DyskeratomaWarty Dyskeratoma
Warty DyskeratomaWarty Dyskeratoma
Cup-shaped acantholysisCup-shaped acantholysis Endophytic epithelial hyperplasia Endophytic epithelial hyperplasia
involving the hair follicle with involving the hair follicle with hyperkeratosis and suprabasal hyperkeratosis and suprabasal cleftingclefting
Corp ronds limited to granular layerCorp ronds limited to granular layer
21.21.Pemphigus VulgarisPemphigus Vulgaris
Pemphigus VulgarisPemphigus Vulgaris
Intraepidermal blister with Intraepidermal blister with suprabasal acantholysissuprabasal acantholysis
Tombstone arrangement of blister Tombstone arrangement of blister cells at the base of the blistercells at the base of the blister
Process extends down hair follicle Process extends down hair follicle epitheliumepithelium
No corps rondsNo corps ronds
Papillary DermalVilli in the Blister Cavity
Intercellular IgG
22.22.Hailey-HaileyHailey-Hailey
Hailey HaileyHailey Hailey
NO Corps Ronds in Granular LayerNO Corps Ronds in Granular Layer ““Wet”- acantholysis with scale crustWet”- acantholysis with scale crust More continuous, not focal like More continuous, not focal like
Darier’sDarier’s Dilapidated Brick WallDilapidated Brick Wall +/- Tombstoning+/- Tombstoning
Dilapidated Brick Wall
23.23.Pemphigus Pemphigus ErythematosusErythematosus
Pemphigus ErythematosusPemphigus Erythematosus Histopathology = Pemphigus foliaceusHistopathology = Pemphigus foliaceus Split in upper epidermis below corneal Split in upper epidermis below corneal
layerlayer Acantholytic cells stick down and up Acantholytic cells stick down and up
into blisterinto blister Some PMN’sSome PMN’s Superficial epidermis can be missingSuperficial epidermis can be missing If you see lots of neuts think SSSS or If you see lots of neuts think SSSS or
bullous impetigobullous impetigo Few neuts = PemphigusFew neuts = Pemphigus
DDxDDx
Bullous Impetigo/SSSS have more Bullous Impetigo/SSSS have more PMNsPMNs
PV and PF: eos and PMNsPV and PF: eos and PMNs
25.25.EACEAC
EACEAC
Superficial perivascular tight-cuffed Superficial perivascular tight-cuffed lymphohistiocytic infiltratelymphohistiocytic infiltrate
Truncal – No hairsTruncal – No hairs No interfaceNo interface No papillary dermal edemaNo papillary dermal edema May see extravasated RBC due to May see extravasated RBC due to
endothelial swellingendothelial swelling
DDxDDx
Lupus (Similar but with interface)Lupus (Similar but with interface) PMLE and CLL ( Similar but with PMLE and CLL ( Similar but with
papillary dermal edema)papillary dermal edema) Jessners (on the face so you will see Jessners (on the face so you will see
hair follicles)hair follicles) Arthropod bites (Eos)Arthropod bites (Eos) Syphilis (Plasma Cells)Syphilis (Plasma Cells) Gyrate erythemaGyrate erythema
26.26.Secondary SyphilisSecondary Syphilis
Secondary SyphilisSecondary Syphilis
Often presents as lichenoid, look for Often presents as lichenoid, look for plasma cellaplasma cella
May be lichenoid + granulomatousMay be lichenoid + granulomatous HypergranulosisHypergranulosis Lymphs and plasma cellsLymphs and plasma cells Colloid bodiesColloid bodies
QuizQuiz