asdp 2017 - baltimore infections mimicking inflammatory ... · 22 blastomycosis •caused by...
TRANSCRIPT
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Napa Valley Dermatopathology Meeting 2018 -
Select Infections & Infestations
Whitney A. High, MD, JD, [email protected]
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”
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Epidermal
Necrosis
Vesiculation
Multinucleated
Keratinocytes
Acantholysis with
“Cytopathic Effect”
Eosinophilic
Intranuclear Inclusions
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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
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Tip:VZV (and sometimes HSV) may
be very folliculocentric in nature
Tip: viral infections can be confused with lymphomas
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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
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Histology
20x
40x
CD20 Stain
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HSV Stain
PCR (+) HSV II
Cx (+) ACV resistant strain
20x10x 40x
Diagnosis: Acyclovir resistant HSV II infection
Bacterial Infections
76 year-old man
Fremont County, Colorado
“rash x years”
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FiteAFB
This is all the
same infection
This is still all the same infection…
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Syphilis!
Tip: There is one disease that can be
included in almost any inflammatory
differential diagnosis -
Secondary SyphilisSuperficial & Deep with Plasma Cells
Copious
Plasma
Cells
This is syphilis…
Lichenoid and slightly psoriasiform
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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 SyphilisImmunohistochemical Studies
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Tip: If syphilis is a possibility, always
recommended serologic testing.
Fungal Infections
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“R/O
PG”
Tip:
Awareness of PG has increased
remarkably, and that is great, but
it is still a “rule out” diagnosis.
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“R/O PG”
In my clinic.
Certainly has
some unusual
features of PG
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Tip:
KOH Prep
It works!
Second Biopsy…
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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
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Protozoal Infections
Unusual Case• 53 year old CU professor
• “SCC of the ear” → Mohs
• After surgery:
– persistent inflammation,
– warmth
– swelling
• Post surgical chondritis?
Ulcer
Serous, hemorrhagic and
inflammatory crusting
Continued inflammatory
infiltrate in the dermis
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Russell body Mott cell
Mostly lymphocytes, histiocytes, plasma cells
Minute “dots” getting even larger yet, among the
otherwise chronic inflammation
Look here!
Case
29 year old woman
Yoga instructor
Recent travel to
Costa Rica
Recent outside dx
of SCC
Sent to Mohs
surgeon
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CDC Results
(free of charge)
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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
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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
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Tip:
Don’t eat raw fish!
Infestations
ScabiesSarcoptes 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
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ScabiesClinical
Wrist area
Penile Nodules
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“Real world” results of a good
scabies prep…
ScabiesCrusted Variant (HIV patient)
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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)
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The Bites
Superficial and
deep perivascular
dermatitis with
eosinophils.
Thank you.