Presenter: Scott Deckelbaum, DO

Dermatology Program: Western University/Pacific Hospital

Program Director: David Horowitz, DO

Submitted on: February 5, 2010

CHIEF COMPLAINT: Progressively worsening diffuse pruritic rash

CLINICALHISTORY: 24-year-old Hispanic male with a complaint of a pruritic rash involving his upper torso and extremities. His symptoms have been slowly progressing over a 5 year period. Our patient reported diffuse pruritus without pain. His complete review of systems was otherwise negative including the presence of palpable masses. No prior treatments. Past Medical, Family and Social History were noncontributory. He immigrated from Mexico around 10 years prior and has no significant employment history.

PHYSICAL EXAM:
Large pink plaques with a fine overlying scale interspersed with violaceous pigmentation distributed in a reticular pattern with some notable telangiectasia and atrophy.

LABORATORY TESTS:

None. Our patient lacked insurance and was unable to comply with a request for blood work or radiography.

DERMATOHISTOPATHOLOGY:

Subacute spongiotic dermatitis with scattered foci of spongiosis accompanied with mildly to moderately atypical lymphocytes. In multiple foci, there are histopathologic changes suggestive of Pautrier microabscesses. There is a perivascular and interstitial lichenoid inflammatory cell infiltrate. Immunohistochemical findings showed strong CD4 positivity and focal loss of CD7 positivity.

DIFFERENTIAL DIAGNOSIS:

1.   Mycosis Fungoides – Poikiloderma Atrophicans Vasculare Variant
2.   Parapsoriasis En Plaque – Large Plaque Variety
3.   Lichen Sclerosis et trophicus
4.   Sceromyxedema