Quiz 40: What is your diagnosis?

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Diagnosis: Quiz 40

Quiz 40

Answer: Herpes simplex

Criteria for diagnosis histopathologically: In addition to a superficial and deep perivascular and interstitial mixed-cell infiltrate joined by marked edema of a widened papillary dermis, the presence of multinucleate epithelial giant cells, even though necrotic, in the context of an intraepidermal blistering disease associated with extensive ballooning of keratocytes and with reticular alteration is indicative of infection by herpesvirus.

Differential diagnosis histopathologically: There is none.

Criteria for diagnosis clinically: Clusters of gray-roofed vesiculopustules on a rust-colored base are those of herpes simplex.

Differential diagnosis clinically: There is none.

Clinicopathologic correlation: The surface of the vesiculopustules is smooth because the cornified layer is normal; the roof of the vesiculopustules is gray because the epidermis is necrotic; the vesicular component is the result of a blister having formed secondary to severe ballooning in the spinous zone; the pustular component is a consequence of countless neutrophils having been attracted chemotactically to the necrotic keratocytes; and the base is rust-colored secondary to a combination of venules and capillaries in the upper part of the dermis having been dilated widely in vivo and of extravasated erythrocytes in the edematous upper part of the dermis and in the epidermis.

Options for therapy predicated on knowledge of histopathologic findings: The vesiculopustules will wane on their own in the course of the next 10 days or so and then will disappear. In short, no treatment is necessary.

1) The nuclear changes in incipiently acantholytic necrotic spinous cells, including those multinucleate, enable a diagnosis of infection by herpesvirus to be issued with confidence, those findings being a blue-gray cast and accentuation of the nucleoplasm at the periphery ("margination" of nucleoplasm).

2) The intraepidermal blister of herpesvirus comes into being secondary to ballooning of spinous keratocytes so extensive that it caused them to explode inevitably with formation of reticular alteration, a phenomenon that results always in confluent epidermal necrosis.

3) Not uncommonly, intraepidermal blistering diseases that come into being by virtue of extraordinary ballooning of keratocytes are accompanied by marked edema in the papillary dermis, that being the situation here. Changes similar to those in this papillary dermis may be encountered, too, in intraepidermal blistering diseases that come about from extensive spongiosis. Practically never, however, does edema riveting in the papillary dermis develop in intraepidermal blistering diseases that are secondary to acantholysis only.

4) Whenever the epidermis of a blistering disease is necrotic, such as in this example of herpes simplex, but also in diseases as disparate as erythema multiforme and milker's nodule, the roof of the clinical blister will be gray, as is the case here.

5) Necrosis is chemotactic for neutrophils, and that not only is exemplified in this section of tissue but it is apparent in caricature here. Ballooning led to reticular alteration which resulted in epidermal necrosis which attracted to it neutrophils (accompanied by nuclear "dust" of them), those polymorphonuclear leukocytes being present in abundance in both the edematous papillary dermis and in the necrotic epidermis.

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