||our first case; ER patient with bullae; DX 2 hours after BX.
||linear BMZ pos.
||IEN-type IgA pemphigus & possible medication effect
||original 1999 Dx. elsewhere on H&E alone
||r/o coll. vasc. dis.
||immune leukocytoclastic vasculitis
||only very acute lesions have vascular fibrinogen
||? linear IgA
||drug vs. SLE
||complex overlap SLE, pemphigus, pemphigoid
||IgG gran. BMZ, linear BMZ & intercellular
||blisters work up
||keratinocytic granular ANA and granular cytoplasmic (not AMA) detected;
pt. has high RF
||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.
||blisters work up, pregnant (highly suggestive of HG)
||herpes gestationis DX by the thawed H&E plus clinical
||DIF agents neg
||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
||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
||photo-dermatitis, r/o psoriasiform
||some parabasal keratocyte balooning and sparse basal vacuolar. Probable lupus...watch 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)
||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
||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
|| 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
|| 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
|| 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.
|| 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.
|| 34 y/o, left cheek DLE-like lesion...is 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.
|| 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.
|| 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.
|| 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])
|| 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.
|| 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.
|| 57y/o F, r/o BP vs. PCT.
||except for actinic dermis, vessels & skin normal by H&E...no eosinophils & w/ DIF = PCT
||DIF pos. for linear BMZ IgG & C3 & homogeneously in dermal vessels
|| 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.
||skins of back
||59 F, dermatomyositis v. lupus v. Wegener's v. vasculitis
||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
||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
||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
||skin lesion shoulder
||57 F, BP vs pemphigus vs allergic
||H&E cleft & ? acantholysis, w/ DIF = pemphigus
||DIF chickenwire epidermal pos IgG & C3
||59 M, BP vs. PV vs EBA
||pericellular IgG, IgA, C3 & F
||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)
||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
||skin lesion upper back
||62 M r/o lupus
||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
||64 F BP vs LP
||wedged hypergranulosis by H&E plus numerous polyclonal globular bodies by DIF
||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
||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
||H&E neg; 1+ venule endothelial fibrinogen positivity
||H&E hyperkeratosis & focal interface dermatitis; DIF = clusters of numerous cytoid bodies as in LP & Gottron's lesions of DM
||r/o pemp. vulg.
||H&E subepidermal blister & some eos. & IgG & C3 BMZ linear DIF positive = BP & NOT PV
||r/o HSV, Behcets, cic. pemphigoid, chancroid, & syphillus
||negative for pemphigoid
||IgG & C3 pericellular positive
||lamina propria cells weakly IgA pos.
||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".
||strong fibrinogen classical shaggy BMZ positivity (of LP, lichenoid drug, and licenoid photodermatitis)
||esophageal mucosa by endoscopic biopsy
||biopsy only had the epithelial layer
||chest skin and deltoid muscle
skin: IgG in vivo ANA
muscle: early perifascicular changes,
all c/w early dermato.
||a single left palm lesion
||HSV, EM, bullous tinea
||IgG & C3 pos. epidermal marking & those cells H&E necrotic (local TEN-like)