Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
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        Some of Our Skin Cases Solved by DIF

Since the 1980s & still as the only community hospital lab in S. C. with this DIF service, we have processed from 1-5 cases per week, and the following are just a very few examples. We have had cases in the ER & ICU as well as others with lesser demand for rapid TAT. See notes about proper DIF sampling and diagnostic features of various skin diseases. The most effective way to deal with these cases is with (by 1) good clinical DDX by dermatologist, (2) shave biopsy for DIF, (3) shave biopsy for H&E, and (4) a serum sample for anti-skin antibody screen by IFA. Rarely, we have worked with skin and muscle biopsy at same time to address such as dermatomyositis.

case number sample clinical ?/diagnosis final path. diagnosis notes
LMC-85-? skin our first case; ER patient with bullae; DX 2 hours after BX. BP linear BMZ pos.
LMC-01-614 skin TEN meds related?  
S01-10098 skin SPD IEN-type IgA pemphigus & possible medication effect original 1999 Dx. elsewhere on H&E alone
S01-7524 skin r/o coll. vasc. dis. immune leukocytoclastic vasculitis only very acute lesions have vascular fibrinogen
S01-7511 skin EBA c/w EBA  
S01-5314 conjunctiva occular pemphigoid ? linear IgA  
S01-5237 skin lupus MCTD  
S01-4984 skin drug vs. SLE complex overlap SLE, pemphigus, pemphigoid IgG gran. BMZ, linear BMZ & intercellular
S03-8966 skin blisters work up   keratinocytic granular ANA and granular cytoplasmic (not AMA) detected; pt. has high RF
S06-13997 skin pruritic work up, r/o DH extensive H&E of thawed DIF biopsy, negative for polys @ papilla tips = DH is ruled out. DIF agents neg.
S06-14029 skin blisters work up, pregnant (highly suggestive of HG) herpes gestationis DX by the thawed H&E plus clinical DIF agents neg
S06-15825 skin photo-type rash work up, r/o SLE superficial inflammation, probably photo-toxic, w/ epidermal in vivo ANA suggesting MCTD, lupus, or other connective tissue disease DIF agents neg except IgG strongly epidermal nuclear ANA positivity
S07-135 skin DH vs BP, PV, EBA superficial papillary dermal edema w/ epidermal in vivo ANA suggesting MCTD, lupus, or other connective tissue disease DIF agents w/ only faintly granular BMZ C3 & IgG strongly positive speckled epidermal nuclear ANA positivity
S07-302 skin photo-dermatitis, r/o psoriasiform some parabasal keratocyte balooning and sparse basal vacuolar. Probable for psoriasis DIF agents w/ only strong granular BMZ IgG, IgA, & C3 positivity (pos. "lupus band") plus the same agents deposited intra-epidermally around intra-corneal clusters of polys (psoriasis-like)
L07-1119 skin 86 y/o in ICU: severe 3rd space edema due to CHF & renal failure and pre-blistering "look", r/o beginning EM/TEN some possible sparse basal keratocyte basal vacuolar degen.; DIF negativity & presence of marked edema & probably basal vac. due to toxic and low-grade hypoxic; doubt EM/TEN DIF agents all negative
L07-1189 skin 60 y/o: pyoderma ganrenosum vs., vs. EM, vs. bullous SLE, vs. fixed drug some sparse basal keratocyte degen.; BMZ DIF negativity & presence of basal cytoplasmic positivity favors EM/TEN DIF basal keratocyte cytoplasmic pos. G, A, M, & C3 & BMZ negative; thawed H&E focal basal cell damage plus melanophages
S07-1538 skin 46 y/o S/P transplant for CML, r/o GVH much melanophage presence & some basal keratocyte vacuolar degen.; in vivo ANA suggesting MCTD & casting doubt on GVH DIF agents all negative except trace to 1+ focal keratocyte cytoplasm pos. & 1-2+ speckled IgG epidermal nuclear ANA positivity
S07-2225 skin 47 y/o with blisters backs of hands H&E looks like PCT; but did IgG DIF looking for in vivo keratocyte ANA as possible evidence of PCT associated collagen vascular disease IgG-only DIF done and showed smooth mural positivity of papillary dermal vessel walls and keratocyte nuclear ANA negativity
S07-2265 skin 72 y/o , left upper back BX, BP vs. DH DIF BP & DH negative; so, rapid thaw and process for H&Es = negative; both diagnoses unlikely DIF = dermal vessels IgG mildly remindful of PCT...probably just an actinic phenomenon. Go to H&E.
S07-3037 skin 46 y/o, right cheek lesion = folliculitis vs. psoriasis vs seb. derm., r/o lupus DIF BMZ "lupus band test" neg.; so, rapid thaw and process for H&Es = negative for spongiosis, interface, or psoriasiform change; deposits c/w acquired localized ochronosis & some chronic follicular inflammation = folliculitis related to bleaching? DIF battery & BMZ "lupus band test" neg.; go to H&E.
S07-3110 skin 34 y/o, left cheek DLE-like it DLE?, r/o BCC rapid thaw and process for H&Es = negative for BCC; IgG-only DIF = BMZ "lupus band test" pos.; go to H&E to r/o the BCC.
L07-2485 skin 59 y/o w/ UTI, trunk H&N acute painful, erythroderma, exanthematous; steroid TX...mid-afternoon BX, concern EM, SJ, TEN. rapid thaw and process for H&Es = AGEP FS DX as DIF slides being cut = DX of probable subcorneal pustulosis problem & DIF then not impetigenized pemph. foliaceus & no evidence EM/SJ TEN.
L07-3526 skin 59 y/o, vessiculating lower legs with venous insufficiency & possible cellulitis & r/o immunobullous. H&E BX plus rapid thaw and process for H&Es = no suggestion of cellulitis & pos. for prominent stasis change & epidermal spongio-edema; DX = not cellulitis & is vesicular, bullous stasis dermatitis stasis vessels fibrinogen-only DIF positive = c/w inflammed vascular component of stasis dermatitis.
S07-8288 normal skin 61y/o, r/o SLE, SCLE, CCLE pretty good evidence against the r/o diseases DIF negative, including negativity for epidermal nuclear ANA (epidermal nuclear staining [ENS])
S07-8599 skin lesion 69y/o, r/o DH vs. BP. DIF c/w DH; H&E slightly concerning for lupus (overlap?) = address on clinical & serological grounds DIF only pos. for finely granular IgA heaviest over dermal papillae. H&E neg for tip polys but has some superficial & deep chronic inflammation.
S07-9508 skin lesion 59y/o F, r/o "limited BP" vs. hydroa estivale (has only had a few blisters in her life). IFA anti-skin abs pos. @ 1:80 for PV-like intercellular (can see with BP) & H&E notes numerous dermal eos. & w/ DIF = probable BP DIF neg. for BMZ & trace vascular pos. IgM & C3.
S07-10963 skin lesion 57y/o F, r/o BP vs. PCT. except for actinic dermis, vessels & skin normal by H& eosinophils & w/ DIF = PCT DIF pos. for linear BMZ IgG & C3 & homogeneously in dermal vessels
S07-11104 skin lesion 18y/o F, r/o "HSP". H&E= pustule over suppuration. DIF pos. for granular vascular IgA, C3 & fibrinogen in dermal capillaries indicative of HSP.
S07-14407 skins of back 59 F, dermatomyositis v. lupus v. Wegener's v. vasculitis  
S07-14996 skin lesion 56 y/o F, r/o LE H&E neg = favor some type cutaneous LE DIF BMZ granular pos. faint in epidermis & much more in adnexa
L08-87 skin lesion (pathologist consulted, surgeon BX) 76 y/o F, exfoliating dermatosis = EM/TEN? H&E parakeratosis & some basal vacuolation & neg DIF = favor medication reaction DIF totally negative
S08-1012 skin lesion 50 y/o F, vasculitis H&E some vessel fibrin thrombi = immune-mediated vasculitis c/w Wegener's DIF multi-agent vascular deposits & we got serum ANCA positive
S08-1211 skin lesion shoulder 57 F, BP vs pemphigus vs allergic H&E cleft & ? acantholysis, w/ DIF = pemphigus DIF chickenwire epidermal pos IgG & C3
S08-4490 skin lesion 59 M, BP vs. PV vs EBA pemphigus pericellular IgG, IgA, C3 & F
S08-4794 skin lesion hand 76 F r/o BP c/w BP & also suspicious for PCT linear BMZ & focal mild PCT-like vascular (IgG, IgA, & F)
S08-4838 skin lesion foot 43 F BP vs. bullous eczema vs bullous LP immune-mediated dermatosis of uncertain classification 1+ linear BMZ IgG & "stasis-like" papillary dermal vessels pos. for IgM, C3, & F
S08-16663 skin lesion upper back 62 M r/o lupus lichen planus 1+ granular BMZ IgG & C3 plus myriad papillary dermal globular bodies (when very numerously present it is LP; small numbers may not r/o LP but myriad is diagnostic) IgA & IgM
S09-122 gingiva 64 F BP vs LP lichen planus wedged hypergranulosis by H&E plus numerous polyclonal globular bodies by DIF
S09-155 skin dorsal hand DH vs PCT vs factitial vs drug not factitial, PCT or DH some nonspecific BMZ DIF pos.; and H&E = scant spongiosis
S09-640 buccal mucosa 79 F erosive LP? LP & autimmuno overlap syndrome vague wedged hypergranulosis by H&E plus DIF in-vivo IgG ANA plus numerous IgA & IgM globular or cytoid bodies
S09-1981 forearm lesion 46 F unknown signif. H&E neg; 1+ venule endothelial fibrinogen positivity
S09-2138 wrist 49 F probable dermatomyositis H&E hyperkeratosis & focal interface dermatitis; DIF = clusters of numerous cytoid bodies as in LP & Gottron's lesions of DM
S09-2512 abdomen 56 M r/o pemp. vulg. H&E subepidermal blister & some eos. & IgG & C3 BMZ linear DIF positive = BP & NOT PV
S09-11046 perinium 51 F r/o HSV, Behcets, cic. pemphigoid, chancroid, & syphillus negative for pemphigoid
S10-3299 esophagus 32F blistering esophagus? IgG & C3 pericellular positive
S10-1431 sigmoid colonic 15M IgA deficiency? lamina propria cells weakly IgA pos.
S10-4995 forearm 72M BP vs. DH vs ? weak granular BMZ (evidence of some sort of background connective tissue disease vs. actinic effect; and fluffy, compacted dermal IgM deposits of actinic elastosis vs. "macroglobulinemia cutis".
S10-11310 buccal mucosa 50F erosive LP? strong fibrinogen classical shaggy BMZ positivity (of LP, lichenoid drug, and licenoid photodermatitis)
S11-5039 esophageal mucosa by endoscopic biopsy 56M linear IgA? biopsy only had the epithelial layer
L11-11282 chest skin and deltoid muscle   dermatomyositis?

skin: IgG in vivo ANA
muscle: early perifascicular changes,
all c/w early dermato.

S12-3318 a single left palm lesion 58F HSV, EM, bullous tinea IgG & C3 pos. epidermal marking & those cells H&E necrotic (local TEN-like)
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