Quiz 34: What is your diagnosis?

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Diagnosis: Quiz 34

Quiz 34

Answer: Verruca palmaris

Criteria for diagnosis clinically: Discrete, skin-colored, slightly keratotic papules on the palm are those of verrucae caused by papillomavirus.

Differential diagnosis clinically: These cannot be papules of secondary syphilis because there is no sign of inflammation. The possibility of punctuate porokeratosis could be entertained and biopsy is crucial to coming to a diagnosis with exactness.

Criteria for diagnosis histopathologically: Beneath a subtle dell, viable epidermis, papillate in foci, strikingly hypergranulotic and hyperplastic with thin rete ridges that "arborize" at the periphery, as well as dilated tortuous capillaries in thin dermal papillae are findings of a verruca situated on a palm or sole.

Differential diagnosis histopathologically: There is none.

Clinicopathologic correlation: The papule is formed by hyperplasia of both the viable and nonviable epidermis, and it is slightly keratotic because of the hyperkeratosis.

Options for therapy predicated on knowledge of histopathologic findings: On the basis of the changes observable at scanning magnification of a conventional microscope, this particular verruca palmaris can be told to have involuted largely. That being so, no treatment is necessary; it is merely a matter of time before the lesions regress completely. If the patient desires therapy, the papules can be curetted gently and electrodesiccated lightly.

1) The diagnosis histopathologic of this example of verruca palmaris can be made at scanning magnification. Nothing else besides infection of volar skin by papillomavirus results in a dell surmounted by compact orthokeratosis and a viable epidermis marked by prominent hypergranulosis and hyperplasia in the form of thin rete ridges that at the periphery of the lesion bend towards the center of it ("arborization"), those changes being accompanied by capillaries rivetingly tortuous in dermae papillae. In short, that constellation of findings is specific for infection by papillomavirus.

2) By virtue of knowledge of the character of these lesions histopathologically, a physician managing this patient can do that rationally, to wit, eschew excising any of the lesions because the cells infected by papillomavirus are all epidermal keratocytes and it is they alone that must be removed. When lesions such as these are shaved, little by little, with the blade of a scalpel there comes a point at which "bleeding puncta" appear. Each of those minute hemorrhages emanates from a tortuous capillary whose loop at the apogee of it was severed.

3) Even though the features clinical and the findings histopathologic pictured here are characteristic of a largely involuted wart, clinicians and histopathologists sometimes diagnose the lesions as "punctuate keratoderma," or some variation of it, those being designations generic and lacking specificity entirely. The diagnosis, in actuality, is verruca palmaris.

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