We present a 47-year-old man with a sudden eruption of more than 100 reddish-brown papules, which histologically exhibited a dense dermal proliferation of large mononuclear cells with vesicular nuclei and abundant pale cytoplasm. Electron microscopy and immunohistochemistry revealed findings consistent with indeterminate cell histiocytosis and the patient responded well to treatment with narrowband UVB therapy. Case synopsis:A 47-year-old, otherwise healthy man with a history of mild plaque psoriasis presented to his dermatologist for evaluation of two asymptomatic, reddish brown, dome shaped papules on his abdomen. The lesions had been present and asymptomatic for several weeks and further evaluation and treatment was initially deferred given the banal appearance of the lesions. In ensuing weeks however, the number of similar appearing lesions increased and spread centrifugally from his trunk to his extremities and face. When the patient returned for a follow up several weeks later, he had over a hundred lesions involving his entire body, but most prominent on this trunk (Figures 1 and 2). Punch biopsies of representative lesions were obtained at this time. A systemic workup was also performed as even though the patient remained in good health, the sudden increase in the number of skin lesions raised concern for internal disease. A systemic workup including bone marrow biopsy, computed tomography scan of the chest, abdomen and pelvis, complete blood count, and complete metabolic panel was performed. The results of these evaluations were normal except for a mild thrombocytopenia. Given the negative systemic work up and the patient's continued overall good health, concern for systemic involvement was considered minimal.
A 63-year-old man presented with an expanding wound on the dorsal aspect of the left hand after striking it on a wall. He sustained a small laceration that progressively became more edematous and developed a violaceous border. He presented to the emergency department the following day and was prescribed bacitracin with no improvement in the lesion. He returned to the emergency department after the symptoms worsened and was subsequently prescribed a 10-day course of oral trimethoprim-sulfamethoxazole (1600/320 mg) twice daily. Physical examination at a follow-up visit 11 days after the initial injury revealed an expanding, 4.3×5.0-cm, ulcerated wound with surrounding erythema and serosanguineous drainage (left). He was started on a 10-day course of amoxicillin-clavulanic acid (1750/250 mg) twice daily and underwent debridement the same day. On postoperative day 2 (13 days following the onset of symptoms), the wound had not improved, and 2 new 1-cm bullae on the left first and second fingers had progressed (right). Erythrocyte sedimentation rate (33 mm/h [reference range, 0-10 mm/h]) and C-reactive protein (3.701 mg/dL [reference range, 0-0.747 mg/dL]) were elevated; however, other laboratory studies, including a complete blood cell count, were within reference range. He remained afebrile, and a review of systems was normal. Punch biopsy specimens were obtained. WHAT'S THE DIAGNOSIS? a. blastomycosislike pyoderma b. bullous cutaneous small vessel vasculitis c. Mycobacterium marinum (fish tank granuloma) d. necrotizing fasciitis e. neutrophilic dermatosis of the dorsal hands
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