Dermatologie

050113

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Présentation Clinique

 

 

Clinical Setting

 

H 61 ans Lésions du visage érythémato-squameuses, et atrophique sur le bras, avec bordure érythémateuse, surmontée d'une lésion bourgeonnante, verruciforme. Lesions évoluant depuis plusieurs années.

 

M 61 yo. Erythematous and squamous lesions of the face, with an extensive atrophic plaque of the arm, surrounded by an erythmatous ring, and centered by a verrucous tumor.

Biopsies Chirurgicales

 

Surgical Biopsies

 

 

 

 

Demodex Folliculorum

 

 

 

PAS- and Acid Fast Negative

 

 

 

 

     
         
     
         
     
         

Diagnostic Proposé:

Dermite granulomateuse compatible avec un lupus vulgaire et,

Carcinome épidermoide verruqueux.

Proposed Diagnosis:

Granulomatous dermatitis consistent with lupus vulgaris,

Verrucous Squamous Cell Carcinoma.

         

 

Lupus vulgaris

  (Tuberculosis in Skin Pathology, D. Weedon, 2nd Ed. Churchill-Livingstone)

 

Lupus vulgaris is the most common form of reinfection tuberculosis, occurring predominantly in young adults. It is caused almost exclusively by M. tuberculosis although rare reports implicating the M.avium-intracellulare complex and M. bovis have been published. It has followed BCG vaccination. Lupus vulgaris affects primarily the head and neck region, although in Southeast Asia it appears to be more common on the extremities and buttocks. Penile involvement can occur. Lesions involving the nose and face can be destructive. The usual picture is of multiple erythematous papules forming a plaque, which on diascopy shows small apple jelly nodules. Crusted ulcers, local cellulitis and dry verrucous plaques are sometimes seen. The disease runs a chronic course and may result in significant scarring. Late complications include the development of contractures, lymphedema, squamous carcinoma and, rarely, basal cell carcinoma, malignant melanoma, and cutaneous lymphomas.

 

Histopathology

In lupus vulgaris there are tuberculoid granulomas with a variable mantle of lymphocytes in the upper and mid dermis. The granulomas have a tendency to confluence. Rarely they have a perifollicular arrangement. Caseation is sometimes present. If prominent caseation is present in a facial lesion, granulomatous rosacea also needs consideration. Multinucleate giant cells are not always numerous. Langerhans cells are present in moderate numbers in the granulomas. The overlying epidermis may be atrophic or hyperplastic, but only rarely is there pseudoepitheliomatous hyperplasia. Transepidermal elimination of granulomas through a hyperplastic epidermis is rarely seen. Bacilli are usually sparse and difficult to demonstrate in sections stained to show acid-fast organisms. They can now be demonstrated using the polymerase chain reaction. In one report, Michaelis-Gutmann bodies were present in macrophages in the infiltrate.

Sometimes the histological appearances resemble sarcoidosis, with only a relatively sparse lymphocytic mantle around the granulomas: a consequent delay in making the correct diagnosis is common in such cases.