Quiz 44: What is your diagnosis?

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Diagnosis: Quiz 44

Quiz 44

Answer: Venous ulcer with dermal scar and subcutaneous sclerosis following on membranous fat necrosis

Criteria for diagnosis histopathologically: The constellation of ulceration, granulation tissue in the uppermost part of the dermis, striking stasis changes in the form of a markedly increased number of dilated thick-walled blood vessels lined by plump endothelial cells in the upper third of the dermis, fibrosis throughout the reticular dermis and in loci within a lobule of the subcutaneous fat, where it appears as sclerosis consequent to the formation of membranous fat necrosis, sums to a diagnosis of venous ulcer.

Differential diagnosis histopathologically: Because of the dramatic signs of severe stasis, it may be inferred that this ulcer resulted from the effects of a system of veins compromised seriously. Although, theoretically, this could be an ulcer induced by trauma to the leg of a person whose venous supply of blood is inadequate, the more likely possibility is that all the changes depicted here are secondary to a major impairment of the venous system. That assessment is confirmed in the first clinical photograph by the presence overt of varicosities situated below the ankle.

Criteria for diagnosis clinically: The large ulcer positioned immediately above varicosities having a bed that sports "proud flesh" covered in loci by fibrinous material and surrounded by a scalloped dusky rim elevated slightly, the ulcer itself being punctuated by zones of reconstituted skin, is typical of that which results from severe venous insufficiency.

Differential diagnosis clinically: This cannot be pyoderma gangrenosum because the border of the lesion is not sufficiently violaceous, boggy, nor overhanging.

Clinicopathologic correlation: The ulcer clinical is a reflection of the ulcer histopathologic; the zones of "proud flesh" represent granulation tissue and are shiny because fibrin sits atop it; and the white zones that interrupt the "proud flesh" represent re-epithelialized epidermis in conjunction with a scar, the component epithelial not being captured in this particular section from the punched out biopsy specimen.

Options for therapy predicated on knowledge of histopathologic findings: By virtue of the compelling evidence of venous insufficiency in the form of pronounced stasis changes, attention must be directed first to rectifying as best as possible the badly compromised vasculature. The approach to therapy, however, should be multidimensional, including attempts at reversing the underlying venous insufficiency by elevation and compression of the leg and measures designed to encourage formation of a new epidermis to eventually cover the ulcer, such as by debridement and possibly pharmacotherapy systemic.

1) The florid fibroplasia that extends throughout the reticular dermis qualifies as a scar by virtue of there being a marked increase in the number of plump fibrocytes associated with coarse but fibrillar bundles of collagen, that combination of attributes being accompanied by telangiectases. The fibrosis that eventuated in scar in the dermis followed on deep ulceration secondary to severe stasis.

2) The fibrosis in the subcutaneous fat qualifies as sclerosis, that is, a decrease dramatic in the number of fibrocytes in company with "homogenization" of collagen (i.e., discrete bundles no longer are visualizable). In this instance, that distinctive expression of long-standing fibrosis is consequent to necrosis of adipocytes, manifested here as so-called membranous fat necrosis, the congealed fat appearing in fashion crenulate at the periphery of spaces that formerly housed adipocytes.

3) The septum seated beneath the affected fat lobule is widened considerably by fibrosis indicative of a later stage in the process of a scar than that which is evident throughout the reticular dermis.

4) The three common types of "leg ulcers" are designated venous, arterial, and neurophathicThose ulcers differ from one another by dint of location and appearance of the ulcer itself, symptoms mostly commonly associated with it, and changes gross either affiliated or not affiliated on the leg affected, e.g., presence or absence of varicosities, of shiny atrophic skin, or of Charcot joints.

5) As a rule, a venous ulcer tends to appear above a medial malleolus or lateral to it and the ulcer itself is protean in shape (e.g., vaguely rectangular and even encircling of the leg with a ragged border) and has a shallow base that sports "proud flesh" (i.e., granulation tissue). By contrast, an arterial ulcer develops more distally over bony prominences and the ulcer itself inclines to be round with a sharply demarcated border and a deep base that at times may penetrate to a tendon covered sometimes by an eschar.

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