Cutaneous Aspergilloma Caused by Aspergillus niger in an Immunocompetent Patient.

An 82-year-old man presented with a growth on his scalp for 7 months. It was increasing in size despite treatment with a variety of shampoos and systemic plus topical antibiotics. It was pruritic with a burning sensation. Lately, the patient had a body weight loss of 35 pounds. Extensive work-ups for malignancy included computerized axial tomography (CAT) and examinations of the gastrointestinal and respiratory tracts; however, no etiology for this weight loss was established. This was not thought to be directly related to the scalp lesion. Work-ups for any infectious etiology, including blood cultures, were proven to be noncontributory. His past medical included chronic obstructive pulmonary disease and gastritis. He also patient had a long history of tobacco use.

A Physician's Guide to the Use of Gene Expression Profile Ancillary Diagnostic Testing for Cutaneous Melanocytic Neoplasms.

Objectives: Some melanocytic neoplasms suspicious for melanoma require additional workup to arrive at a final diagnosis. Within the last eight years, gene expression profiling (GEP) has become an important ancillary tool to aid in the diagnosis of melanocytic neoplasms with uncertain malignant potential. As the usage of two commercially available tests (23-GEP and 35-GEP) evolves, it is important to answer key questions about optimal utilization and their impact on patient care. Methods: Recent and relevant articles answering the following questions were included in the review. First, how do dermatopathologists synthesize the available literature, the latest guidelines, and their clinical experience to determine which cases would be most likely to benefit from GEP testing? Second, how best can a dermatologist convey to their dermatopathologist that the use of GEP in the diagnostic process could provide a more clearly defined result and thereby help empower the dermatologist to provide higher-quality patient care when making specific patient management decisions for otherwise pathologically ambiguous lesions? Results: When interpreted in the context of the clinical, pathologic, and laboratory information, GEP results can facilitate the rendering of timely, accurate, and definitive diagnoses for melanocytic lesions with otherwise uncertain malignant potential to inform personalized treatment and management plans. Limitations: This was a narrative review focused on clinical use of GEP compared to other ancillary diagnostic tests performed postbiopsy. Conclusion: Open communication between dermatopathologists and dermatologists, especially regarding GEP testing, can be a vital component to achieve appropriate clinicopathologic correlation for otherwise ambiguous melanocytic lesions.

COVID-19 Vaccine-Induced Lichenoid Eruptions-Clinical and Histopathologic Spectrum in a Case Series of Fifteen Patients with Review of the Literature.

Lichen planus is a distinctive mucocutaneous disease with well-established clinical and histopathologic criteria. Lichenoid eruptions closely resemble lichen planus and may sometimes be indistinguishable from it. Systemic agents previously associated have included medications, viral infections and vaccines. Sporadic case reports of lichen planus and lichenoid reactions associated with COVID-19 vaccines have recently emerged. Herein, we review the world literature (31 patients) and expand it with a case series of 15 patients who presented with vaccine-induced lichenoid eruption (V-ILE). The spectrum of clinical and histopathologic findings is discussed with emphasis on the subset whose lesions manifested in embryologic fusion lines termed lines of Blaschko. This rare Blaschkoid distribution appeared in seven of the 46 patients studied. Of interest, all seven were linked to the mRNA COVID-19 vaccines. We believe that all lichenoid eruptions should be approached with a heightened index of suspicion and patients should be specifically questioned with regards to their vaccination history. When diagnosed early in its course, V-ILE is easily treated and resolves quickly in almost all patients with or without hyperpigmentation. Additional investigative studies regarding its immunopathology and inflammatory signaling pathways may offer insight into other Th1-driven autoimmune phenomena related to COVID-19 vaccination.

Subtlety of Granulomatous Mycosis Fungoides: A Retrospective Case Series Study and Proposal of Helpful Multimodal Diagnostic Approach With Literature Review.

ABSTRACT: Granulomatous mycosis fungoides (GMF) harbors a worse prognosis compared with classic MF and remains a significant diagnostic dilemma. We analyzed clinicopathologic, immunophenotypic, and molecular characteristics of GMF to develop a diagnostic algorithm. Our methodology involved a retrospective case series study of patients with GMF from our database between 2014 and 2020. A total of 8 patients with 9 biopsies of GMF were identified. Skin manifestations had variable clinical phenotype. Histologically, all cases demonstrated atypical CD4 + T-cell infiltrate with scant in 50% (n = 4), focal 37.5% (n = 3), and absent 25% (n = 2) epidermotropism. Granuloma formation was seen in 77.8% biopsies (n = 7) with sarcoid-type granulomas in 57.1% (n = 4) and granuloma annulare-like type in 42.9% (n = 3). In 66.7% of biopsies (n = 6), the CD4:CD8 ratio was >4:1 and 66.6% (n = 6) of biopsies showed ≥50% loss of CD7 expression. T-cell receptor gene rearrangement studies performed on biopsy sections were positive in all biopsies (n = 6), whereas peripheral blood T-cell receptor gene rearrangement studies did not identify clonality. In conclusion, GMF has subtle or absent epidermotropism and variable granulomatous reaction; thus, the diagnosis requires a multimodal approach, and our proposed algorithm provides a framework to approach this diagnostic challenge.

Unilateral Verrucous Psoriasis.

Verrucous psoriasis is a variant of psoriasis that presents with wartlike clinical features and overlapping histologic features of verruca and psoriasis. The disease typically arises in patients with established psoriasis but can occur de novo. We report the case of an 80-year-old man with a history of hypertension and coronary artery disease who presented with a rash characterized by multiple asymptomatic plaques with overlying verrucous nodules on the left side of the body. The lesions appeared shortly after coronary artery bypass surgery with a saphenous vein graft.

Oral lymphangiectasia and gastrointestinal Crohn disease.

Lip edema with non-caseating granulomas or lymphangiectasia pose a clinical and pathological challenge. These findings can be attributed to cheilitis granulomatosa (CG), Melkersson-Rosenthal syndrome (MRS), or Crohn disease (CD) depending on the appropriate clinical context. Lymphangiectasis, in particular, is a common pathological finding in CD due to lymphatic obstruction by granulomas and intralymphatic granulomas. Because oral symptoms can precede gastrointestinal symptoms of CD or be seen in patients with asymptomatic gastrointestinal disease, the identification of lymphangiectasia should raise the possibility of underlying CD. We present a case of a young woman with several years of lip swelling, with notable lymphangiectasia and subtle granulomas on pathological evaluation. The patient was diagnosed with MRS at an outside institution and treated with systemic steroids, without further systemic evaluation. We believe that early recognition of lymphangiectasia and consideration of CD early in the work-up are critical for early diagnosis and appropriate management. Neither clinical nor histopathological findings should be used in isolation to diagnose GC, MRS, or CD as there is significant debate as to the etiology and overlapping findings of these conditions. We highlight the importance of lymphangiectasia in diagnosing underlying CD in the appropriate clinical context.

Investigating the histopathological findings and immunolocalization of rickettsialpox infection in skin biopsies: A case series and review of the literature.

BACKGROUND: Recognition of rickettsialpox infection on skin biopsy can be challenging. The histopathology is non-specific and inconsistently described. We assess classic histopathologic features in confirmed cases and review the literature. METHODS: We searched for cases of "rickettsialpox" diagnosed between 2006 and 2018 with positive immunostaining for Spotted Fever Group Rickettsia species. Original slides were evaluated for vacuolar alterations, granulomatous inflammation, vasculitis, necrosis, fibrin thrombi, microvesiculation, papillary dermal edema, and extravasated red blood cells. All biopsies were stained for CD3, CD20, CD68, and myeloperoxidase. RESULTS: Six biopsy specimens were compiled, three of which were sampled from vesiculopapules, one from a maculopapule, and two from eschars. Vacuolar alterations and vasculitis were present in all specimens (6/6; 100%). Granulomatous inflammation was present in five specimens (5/6; 83.3%). Fibrin thrombi and red blood cells were seen in 3/6 (50%) of specimens. The eschars showed necrosis of the epidermis and superficial dermis (2/6, 33.3%). Only one specimen showed intraepidermal vesiculation and papillary dermal edema (1/6; 16.7%). All six specimens showed perivascular infiltration with CD3+ T-cells, and low amounts of CD20+ B-cells and neutrophils. Five of the six specimens (83.3%) showed significant levels of CD68+ histiocytes. CONCLUSION: The histopathology of rickettsialpox infection is septic lymphocytic and granulomatous vasculitis.

Observational Study Examining the Diagnostic Practice of Ki67 Staining for Melanocytic Lesions.

BACKGROUND: Dermatopathologists routinely use Ki67 immunostaining to assess atypical melanocytic lesions with a dermal component to determine whether an ambiguous tumor is melanoma. However, there is no universal standard of use for Ki67 in melanocytic neoplasms. We sought to observe the real-world use of Ki67 in the diagnosis of melanocytic lesions and establish a best practice recommendation. METHODS: We searched dermatopathology reports from 2 academic practices for melanocytic lesions in which Ki67 staining was used for diagnosis. The proliferation rate was compared between cases diagnosed as benign (not requiring re-excision), moderate to severely dysplastic or atypical Spitz nevi (requiring re-excision), and malignant melanoma. The use of other melanocytic markers and consensus review was also recorded and compared between institutions. RESULTS: Pathology reports for 106 cases were reviewed. A high Ki67 proliferation rate (n = 18) favored a diagnosis of melanoma or nevi requiring re-excision (15/18, 83.3%) versus a benign nevus (3/18, 16.67%). A high Ki67 rate was 71.4%-90.9% sensitive and 40%-56% specific for the diagnosis of nevus requiring re-excision or melanoma. Institutional practices differed in regard to reporting of Ki67 staining, the use of multiple markers in the workup of atypical melanocytic lesions (HMB45, Melan-A, Ki67 being most common), and consensus review. CONCLUSIONS: A negative or low Ki67 proliferation rate correlates well with rendering of a benign diagnosis. However, a low proliferation rate does not preclude the diagnosis of melanoma. Ki67 staining is most commonly used as an ancillary test to support a diagnosis after other factors have been considered, such as histopathologic morphology and results of additional concurrently used stains.

Injectable cellulose-based hydrogels as nucleus pulposus replacements: Assessment of in vitro structural stability, ex vivo herniation risk, and in vivo biocompatibility.

Current treatments for intervertebral disc degeneration and herniation are palliative only and cannot restore disc structure and function. Nucleus pulposus (NP) replacements are a promising strategy for restoring disc biomechanics and height loss. Cellulose-based hydrogel systems offer potential for NP replacement since they are stable, non-toxic, may be tuned to match NP material properties, and are conducive to cell or drug delivery. A crosslinked, carboxymethylcellulose-methylcellulose dual-polymer hydrogel was recently formulated as an injectable NP replacement that gelled in situ and restored disc height and compressive biomechanical properties. The objective of this study was to investigate the translational potential of this hydrogel system by examining the long-term structural stability in vitro, the herniation risk and fatigue bending endurance in a bovine motion segment model, and the in vivo biocompatibility in a rat subcutaneous pouch model. Results showed that the hydrogels maintained their structural integrity over a 12-week period. AF injury significantly increased herniation risk and reduced fatigue bending endurance in bovine motion segments. Samples repaired with cellulosic hydrogels demonstrated restored height and exhibited herniation risk and fatigue endurance comparable to samples that underwent the current standard treatment of nucleotomy. Lastly, injected hydrogels elicited a minimal foreign body response as determined by analysis of fibrous capsule development and macrophage presence over 12 weeks. Overall, this injectable cellulosic hydrogel system is a promising candidate as an NP substitute. Further assessment and optimization of this cellulosic hydrogel system in an in vivo intradiscal injury model may lead to an improved clinical solution for disc degeneration and herniation.

Histological findings and pathologic diagnosis of spiradenocarcinoma: A case series and review of the literature.

BACKGROUND: Atypical spiradenoma and spiradenocarcinoma present a diagnostic challenge. We aim to assess the significance of certain histologic features, which may facilitate diagnosis of these tumors. METHODS: A natural language search for cases of "atypical spiradenoma" and "spiradenocarcinoma" diagnosed between 2009 and 2018 was performed. Original slides were retrieved and a subset of cases (n = 5) were stained for Ki-67, p53, carcinoembryonic antigen (CEA), and S100. All cases (n = 7) were assessed for overall architecture, atypical mitotic figures, abnormal cytology, necrosis, ductal proliferation, dilated vessels, and loss of dual cell population. RESULTS: All our cases showed an abrupt transition from benign to malignant morphology, nuclear atypia, atypical mitotic figures, and a monomorphic loss of the dual cell population (7/7; 100%). The majority also had dilated vessels (6/7; 85.7%), and ductal dilation or proliferation (5/7; 71.4%). Fewer cases showed tumor encapsulation (3/7; 43%), massive necrosis (3/7; 43%), and focal cellular necrosis (1/7; 14%). All cases showed a relatively increased Ki-67 proliferation index at the transitional interface (5/5; 100%). Almost all cases stained positively for p53 (4/5; 80%). Malignant areas of tumor or at the transitional interface showed more intense S100 staining (3/5; 60%). All cases were negative for CEA. CONCLUSION: Histologic features that strongly favor atypical spiradenoma or spiradenocarcinoma include abrupt transition to malignant foci, atypical mitotic figures, and monomorphic loss of the dual cell population. Ki-67, p53, and S100 may help delineate areas of atypical or malignant transformation in spiradenomas.

Ripple-Pattern Sebaceous Trichoblastoma.

A 28-year-old man of Middle-Eastern descent presented with a raised, pearly, slightly pigmented lesion on the right nasal ala. The lesion had been present for approximately 4 months. An excisional biopsy was taken, and the lesion measured 1.0 cm × 0.9 cm in dimension. The cut surface revealed a firm, white to tan nodule located within the dermis. The patient had no other significant medical history. After the initial excision, the lesion did not recur.

Syringocystadenocarcinoma Papilliferum: A Rare Malignant Sweat Gland Tumor.

A 73-year-old Hispanic woman presented to the clinic with an erythematous, friable 3.0 cm × 2.7 cm × 0.7 cm mass located on the posterior vertex of the scalp (Figure 1). The lesion had been present since birth but had recently begun to bleed intermittently, prompting evaluation. A biopsy was obtained, revealing a tumor with irregular, complex papillomatous invaginations lined by a two-layered epithelium. Atypical and crowded columnar cells lined the luminal aspect, while cuboidal cells lined the epithelium adjacent to the stroma (Figure 2). Decapitation secretion was noted in several areas on the luminal surface.

Isotretinoin and Surgical Extraction for Adult-Onset Nevus Comedonicus.

We present a case of postmenopausal-onset nevus comedonicus in a 58-year-old white woman with no relevant medical history. Two years before presentation, the patient had had a solitary red nodule, measuring 3.8 cm wide, on the mid lateral region of her left thigh. This progressed to a large area, 11.4 cm wide and 14 cm long, of multiple pruritic and painful red nodules, cysts, and deep open comedones extending across the lateral part of the left thigh, with less severe segmental extension to the lateral aspect of the left leg.