Descriptive (diagnostic) Report
SPECIMEN:
skin biopsies, multiple
MICROSCOPIC:
Examination
of the multiple sections of skin tissue submitted to the laboratory reveals that
they were accompanied with an excellent history.
There are many changes in this tissue that support that this tissue has
been self traumatized.
The inflammation is extending all the way to the deep edges of the dermal
tissue that were submitted, and thus it is extending completely through the
dermis.
There is a massive infiltration of inflammatory cells in the skin which
include epithelioid cells, neutrophils, scattered eosinophils, lymphocytes, and
plasma cells.
This mixed cell accumulation is present throughout the tissue.
In only a few locations do the cellular collections extend to the
epidermis.
Several of us spent time looking for fungal hyphae and could not identify
any.
Degenerate debris is quite prominent and collection is quite
hyperkeratotic.
There are adequate numbers of sebaceous glands in the tissue, and thus
sebaceous adenitis is not an underlying problem.
This reaction is very severe and chronic and, again, bacterial colonies
are not identified in any location, but pyoderma cannot be ruled out.
There are areas of ulceration and erosion.
This reaction is very severe and very deep and there are many ruptured
hair follicles in excellent collections of tissue submitted to this pathologist.
DIAGNOSIS:
SEVERE
CHRONIC PYOGRANULOMATOUS FOLLICULITIS, FURUNCULOSIS, AND DERMATITIS WITH EDEMA.
COMMENTS:
This
collection of tissue is, again, an excellent collection of cutaneous tissue and
was submitted with an excellent history, and there is a massive inflammatory
process throughout the tissue.
The massive inflammatory process, however, appears to be quite deep.
In several locations were are concerned about an allergic process and
pavementing of eosinophils and a few aggregates of eosinophils are present in
the surrounding nonpustular tissue.
The severe furunculosis and folliculitis is commonly associated with
dermatophytosis, and at least 3 pathologists looked for dermatophytes in this
tissue.
They were not identified.
This does not mean that they are not part of the process, since this type
of reaction is commonly seen with dermatophytes with secondary pyoderma.
Interestingly enough, we see very few bacteria.
Another possibility with this type of reaction is idiopathic sterile
granuloma/pyogranuloma syndrome.
This very likely is immune mediated or possibly allergic in nature.
The pustules need to be cultured.
There is no evidence of autoimmune disease, nor is there evidence of
specific infection, but we are concerned about ruling out dermatophytosis and we
are concerned about ruling the condition we have already listed.
Drug eruption with secondary deep furunculosis is still a possibility,
since there are some changes in the tissue that might be the result of allergy.
The possibility of an allergy with secondary trauma and sterile
pyogranulomatous and granuloma syndrome must be considered.