Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
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        Some of Our Skin DIF Cases
      

Since the 1980s & still as the only community hospital lab in S. C. with this DIF service, we have processed from 1-5 cases per week, and the following are just a very few examples. We have had cases in the ER & ICU as well as others with lesser demand for rapid TAT. See notes about proper DIF sampling and diagnostic features of various skin diseases. The most effective way to deal with these cases is with (1) good clinical DDX by dermatologist, (2) shave biopsy for DIF, (3) shave biopsy for H&E, and (4) a serum sample for anti-skin antibody screen by IFA. Some studies reveal immuno-findings which do not seem germain to the dermatologist's DDX & are reported as "of uncertain significance".

case number sample clinical ?/diagnosis final path. diagnosis notes
LMC-85-? skin our first case; ER patient with bullae; DX 2 hours after BX. BP linear BMZ pos.
LMC-01-614 skin TEN meds related?  
S01-10098 skin SPD IEN-type IgA pemphigus & possible medication effect original 1999 Dx. elsewhere on H&E alone
S01-7524 skin r/o coll. vasc. dis. immune leukocytoclastic vasculitis only very acute lesions have vascular fibrinogen
S01-7511 skin EBA c/w EBA  
S01-5314 conjunctiva occular pemphigoid ? linear IgA  
S01-5237 skin lupus MCTD  
S01-4984 skin drug vs. SLE complex overlap SLE, pemphigus, pemphigoid IgG gran. BMZ, linear BMZ & intercellular
S03-8966 skin blisters work up   keratinocytic granular ANA and granular cytoplasmic (not AMA) detected; pt. has high RF
S06-13997 skin pruritic work up, r/o DH extensive H&E of thawed DIF biopsy, negative for polys @ papilla tips = DH is ruled out. DIF agents neg.
S06-14029 skin blisters work up, pregnant (highly suggestive of HG) herpes gestationis DX by the thawed H&E plus clinical DIF agents neg
S06-15825 skin photo-type rash work up, r/o SLE superficial inflammation, probably photo-toxic, w/ epidermal in vivo ANA suggesting MCTD, lupus, or other connective tissue disease DIF agents neg except IgG strongly epidermal nuclear ANA positivity
S07-135 skin DH vs BP, PV, EBA superficial papillary dermal edema w/ epidermal in vivo ANA suggesting MCTD, lupus, or other connective tissue disease DIF agents w/ only faintly granular BMZ C3 & IgG strongly positive speckled epidermal nuclear ANA positivity
S07-302 skin photo-dermatitis, r/o psoriasiform some parabasal keratocyte balooning and sparse basal vacuolar. Probable lupus...watch for psoriasis DIF agents w/ only strong granular BMZ IgG, IgA, & C3 positivity (pos. "lupus band") plus the same agents deposited intra-epidermally around intra-corneal clusters of polys (psoriasis-like)
L07-1119 skin 86 y/o in ICU: severe 3rd space edema due to CHF & renal failure and pre-blistering "look", r/o beginning EM/TEN some possible sparse basal keratocyte basal vacuolar degen.; DIF negativity & presence of marked edema & probably basal vac. due to toxic and low-grade hypoxic; doubt EM/TEN DIF agents all negative
L07-1189 skin 60 y/o: pyoderma ganrenosum vs., vs. EM, vs. bullous SLE, vs. fixed drug some sparse basal keratocyte degen.; BMZ DIF negativity & presence of basal cytoplasmic positivity favors EM/TEN DIF basal keratocyte cytoplasmic pos. G, A, M, & C3 & BMZ negative; thawed H&E focal basal cell damage plus melanophages
S07-1538 skin 46 y/o S/P transplant for CML, r/o GVH much melanophage presence & some basal keratocyte vacuolar degen.; in vivo ANA suggesting MCTD & casting doubt on GVH DIF agents all negative except trace to 1+ focal keratocyte cytoplasm pos. & 1-2+ speckled IgG epidermal nuclear ANA positivity
S07-2225 skin 47 y/o with blisters backs of hands H&E looks like PCT; but did IgG DIF looking for in vivo keratocyte ANA as possible evidence of PCT associated collagen vascular disease IgG-only DIF done and showed smooth mural positivity of papillary dermal vessel walls and keratocyte nuclear ANA negativity
S07-2265 skin 72 y/o , left upper back BX, BP vs. DH DIF BP & DH negative; so, rapid thaw and process for H&Es = negative; both diagnoses unlikely DIF = dermal vessels IgG mildly remindful of PCT...probably just an actinic phenomenon. Go to H&E.
S07-3037 skin 46 y/o, right cheek lesion = folliculitis vs. psoriasis vs seb. derm., r/o lupus DIF BMZ "lupus band test" neg.; so, rapid thaw and process for H&Es = negative for spongiosis, interface, or psoriasiform change; deposits c/w acquired localized ochronosis & some chronic follicular inflammation = folliculitis related to bleaching? DIF battery & BMZ "lupus band test" neg.; go to H&E.
S07-3110 skin 34 y/o, left cheek DLE-like lesion...is it DLE?, r/o BCC rapid thaw and process for H&Es = negative for BCC; IgG-only DIF = BMZ "lupus band test" pos.; go to H&E to r/o the BCC.
L07-2485 skin 59 y/o w/ UTI, trunk H&N acute painful, erythroderma, exanthematous; steroid TX...mid-afternoon BX, concern EM, SJ, TEN. rapid thaw and process for H&Es = AGEP FS DX as DIF slides being cut = DX of probable subcorneal pustulosis problem & DIF then not impetigenized pemph. foliaceus & no evidence EM/SJ TEN.
L07-3526 skin 59 y/o, vessiculating lower legs with venous insufficiency & possible cellulitis & r/o immunobullous. H&E BX plus rapid thaw and process for H&Es = no suggestion of cellulitis & pos. for prominent stasis change & epidermal spongio-edema; DX = not cellulitis & is vesicular, bullous stasis dermatitis stasis vessels fibrinogen-only DIF positive = c/w inflammed vascular component of stasis dermatitis.
S07-8288 normal skin 61y/o, r/o SLE, SCLE, CCLE pretty good evidence against the r/o diseases DIF negative, including negativity for epidermal nuclear ANA (epidermal nuclear staining [ENS])
S07-8599 skin lesion 69y/o, r/o DH vs. BP. DIF c/w DH; H&E slightly concerning for lupus (overlap?) = address on clinical & serological grounds DIF only pos. for finely granular IgA heaviest over dermal papillae. H&E neg for tip polys but has some superficial & deep chronic inflammation.
S07-9508 skin lesion 59y/o F, r/o "limited BP" vs. hydroa estivale (has only had a few blisters in her life). IFA anti-skin abs pos. @ 1:80 for PV-like intercellular (can see with BP) & H&E notes numerous dermal eos. & w/ DIF = probable BP DIF neg. for BMZ & trace vascular pos. IgM & C3.
S07-10963 skin lesion 57y/o F, r/o BP vs. PCT. except for actinic dermis, vessels & skin normal by H&E...no eosinophils & w/ DIF = PCT DIF pos. for linear BMZ IgG & C3 & homogeneously in dermal vessels
S07-11104 skin lesion 18y/o F, r/o "HSP". H&E= pustule over suppuration. DIF pos. for granular vascular IgA, C3 & fibrinogen in dermal capillaries indicative of HSP.
S07-14407 skin lesions of back 59 F, dermatomyositis v. lupus v. Wegener's v. vasculitis an overlap of lupus & pemphigus, others ruled out ? mild & focal basal hydropic change; patchy BMZ granular & patchy peri-keratocyte DIF pos.
S07-14996 skin lesion 56 y/o F, r/o LE H&E neg = favor some type cutaneous LE DIF BMZ granular pos. faint in epidermis & much more in adnexa
L08-87 skin lesion (pathologist consulted, surgeon BX) 76 y/o F, exfoliating dermatosis = EM/TEN? H&E parakeratosis & some basal vacuolation & neg DIF = favor medication reaction DIF totally negative
S08-1012 skin lesion 50 y/o F, vasculitis H&E some vessel fibrin thrombi = immune-mediated vasculitis c/w Wegener's DIF multi-agent vascular deposits & we got serum ANCA positive
S08-1211 skin lesion shoulder 57 F, BP vs pemphigus vs allergic H&E cleft & ? acantholysis, w/ DIF = pemphigus DIF chickenwire epidermal pos IgG & C3
S08-4490 skin lesion 59 M, BP vs. PV vs EBA pemphigus pericellular IgG, IgA, C3 & F
S08-4794 skin lesion hand 76 F r/o BP c/w BP & also suspicious for PCT linear BMZ & focal mild PCT-like vascular (IgG, IgA, & F)
S08-4838 skin lesion foot 43 F BP vs. bullous eczema vs bullous LP immune-mediated dermatosis of uncertain classification 1+ linear BMZ IgG & "stasis-like" papillary dermal vessels pos. for IgM, C3, & F
S08-5441 skin rash right lower back 67 F node neg. breast ca. lymphocytic venulitis, likely drug reaction DIF neg. & ANA pos. but with neg. DNA & ENA
S08-5772     immuno-findings of uncertain signirficance  
S08-6758     immuno-findings of uncertain signirficance  
 
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