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  • Presentation

Great Cases from the Dermatopathology Slide Club

Description

In this presentation, Dr. Kara discusses two pairs of dermatopathology cases focusing on lower extremity hyperpigmentation and a vesicular eruption in immunocompromised patients. The first case involves a 38-year-old female with progressive hyperpigmentation on her legs diagnosed with medium vessel lymphocytic vasculitis and lupus anticoagulant positivity, indicating potential anti-phospholipid antibody syndrome (APS). She had previously experienced shortness of breath but manageable systemic health. The second patient is a 40-year-old female with asymptomatic hyperpigmented lesions also diagnosed with macular lymphocytic arteritis, a rare condition that is benign and notable for its incongruent clinical and histopathologic findings. The next focus shifts to two cases involving immunocompromised individuals. A 37-year-old male with HIV developed hemorrhagic vesicles diagnosed as disseminated herpes simplex virus (HSV), while a 79-year-old female renal transplant recipient presented with crusted lesions diagnosed as disseminated varicella-zoster virus (VZV). Both presented unique diagnostic challenges, emphasizing the need for careful examination of clinical and histopathologic findings. The session reinforces the importance of considering common diseases in unusual forms in immunosuppressed patients and highlights the diagnostic roles of histopathology and PCR testing in these complex cases.

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Conclusions

  • The differential diagnosis for lower extremity hyperpigmentation includes benign conditions such as macular lymphocytic arteritis and serious conditions like antiphospholipid syndrome (APS) and polyarteritis nodosa (PAN).
  • Lupus anticoagulant positivity in patients can indicate a diagnosis of APS, which requires careful clinical evaluation and laboratory confirmation.
  • Macular lymphocytic arteritis is characterized by lymphocytic vasculitis with thrombosis and typically has a benign clinical course.
  • In the context of hypercoagulable states, it is important to consider and screen for APS due to its varied clinical presentations.
  • The vesicular eruption in immunocompromised patients can represent disseminated herpes simplex virus (HSV) infection, requiring specific diagnosis and management.
  • Disseminated HSV may present without traditional cutaneous signs, especially in immunocompromised patients, requiring awareness of subtle presentations.
  • There are significant morphologic differences between disseminated HSV and varicella zoster virus (VZV) infections, and histopathology remains a crucial diagnostic tool.
  • In the setting of opportunistic infections in patients with HIV, the correct identification and treatment of such viral infections can greatly improve patient outcomes.
  • Gomez-Flores M, Herrera-Argaez G, Vazquez-Martinez O, et al. Cutaneous manifestations of antiphospholipid syndrome. Lupus. 2021;30(4):541-548.
  • Mohseni Afshar Z, Goodarzi A, Emadi SN, Miladi R, Shakoei S, Janbakhsh A, Aryanian Z, Hatami P. A Comprehensive Review on HIV-Associated Dermatologic Manifestations: From Epidemiology to Clinical Management. Int J Microbiol. 2023 Jul 18;2023:6203193.
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  • Dupré A, Morel N, Yelnik C, et al. Cutaneous Involvement in Catastrophic Antiphospholipid Syndrome in a Multicenter Cohort of 65 Patients. JAMA Dermatol. 2023;159(1):62-67.
  • Wauters O, Lebas E, Nikkels AF. Chronic mucocutaneous herpes simplex virus and varicella zoster virus infections. J Am Acad Dermatol. 2012 Jun;66(6):e217-27.
  • Stewart JA, Reef SE, Pellett PE, Corey L, Whitley RJ. Herpesvirus infections in persons infected with human immunodeficiency virus. Clin Infect Dis. 1995 Aug;21 Suppl 1:S114-20.
  • Akamatsu M, Kawamura Y, Miura H, Sugimoto E, Okamoto K, Nakajima Y, Kozawa K, Furukawa G, Tanaka M, Kudo K, Yoshikawa T. Systemic herpes simplex virus infection in a child with eczema herpeticum. Pediatr Dermatol. 2023 May-Jun;40(3):582-583.
  • Zampella JG, Vakili S, Doig S, Girardi N, Kwatra SG, Seo P, Patel M. Macular lymphocytic arteritis: Clinical-pathologic correlation of a rare vasculitis. JAAD Case Rep. 2017 Mar 11;3(2):116-120.
  • Pergam SA, Limaye AP; AST Infectious Diseases Community of Practice. Varicella zoster virus in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13622.
  • Rommelaere M, Maréchal C, Yombi JC, Goffin E, Kanaan N. Disseminated varicella zoster virus infection in adult renal transplant recipients: outcome and risk factors. Transplant Proc. 2012 Nov;44(9):2814-7.