Quiz 41: What is your diagnosis?

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Diagnosis: Quiz 41

Quiz 41

Answer: Pyogenic granuloma

Criteria for diagnosis clinically: A dark red papule with a shiny surface, encircled along its lower half by a rim of violaceous skin, is a pyogenic granuloma.

Differential diagnosis clinically: There is none.

Criteria for diagnosis histopathologically: A markedly increased number of closely approximated endothelium-lined spaces in an edematous stroma, the lesion itself being punctuated in its center by an ulcer framed on both sides by scale-crust, is a pyogenic granuloma.

Differential diagnosis histopathologically: There is none.

Clinicopathologic correlation:  The papule is made up of the proliferation of blood vessels coupled with edema in the dermis, the shiny surface is a consequence of fibrin that lies atop the ulcer, and the "lip" that partially envelops the ulcer is formed of volar skin altered by scale-crust beneath which the viable epidermis is thinned.

Options for therapy predicated on knowledge of histopathologic findings: A diagnosis of pyogenic granuloma rendered by a histopathologist should imply to a clinician a lesion that in time is given to involute. In this instance, the pyogenic granuloma was biopsied by shave technique and the base of it subjected to electrodessication. That combination of procedures resulted in elimination of the process pathologic.

1) The term  pyogenic granuloma  is unfortunate because it is a misnomer on both counts, i.e., it is neither pyogenic nor a granuloma. In actuality, a pyogenic granuloma is a hyperplasia of endothelial cells that eventuate in blood vessels, the process initiated usually by trauma external, often in the form of a puncture.

2) Assessment of the attributes morphologic of pyogenic granuloma, both ones clinical and histopathologic, does not permit correct inference to be made of its being a hyperplasia. Only by virtue of following the course chronologic of pyogenic granuloma can it be determined that the lesion, in fact, fulfills criteria for a hyperplasia, i.e., it involutes in time in the absence of any therapy. In classic pathology, it is the inclination to involution that enables differentiation of a  hyperplasia  from a benign neoplasia.

3) Had this lesion been removed in toto, at the base of it in the subcutaneous fat and in the deep reticular dermis would have been observed a "feeder" muscle-containing blood vessel as the source of the proliferation of endothelial cells that resulted in the pyogenic granuloma. Trauma to that larger blood vessel is what started the hyperplasia in motion.

4) Some proliferations of blood vessels in skin are termed "hemangioma" when, in reality, they are a hyperplasia, e.g., strawberry hemangioma, cavernous hemangioma, and lobular capillary hemangioma (which is a synonym for pyogenic granuloma). Others are called "hyperplasia" when, in truth, they are a vascular malformation, that being exemplified best by "angiolymphoid hyperplasia with eosinophils." A serious student of dermatology, general pathology, and dermatopathology must listen with a "third ear" to the language employed routinely in those disciplines and ask him or herself, constantly and insistently, what the process actually is fundamentally vis-à-vis what it is denoted to be. No better example of that disparity can be found than the designation "pyogenic granuloma."

5) Kaposi's sarcoma is  not a sarcoma; in fact, it is not even a neoplasm, but a hyperplasia of endothelial cells that form aberrant thin blood vessels. Kaposi's sarcoma fulfills criteria for a hyperplasia because when the stimulus responsible for bringing it into being, i.e., a herpesvirus, is eliminated, the proliferation of blood vessels ceases and involutes.


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