DERMATOPATHOLOGY CASES: Self-Assessment Cases: Editor - Dr Sampurna Roy MD

Digital Images of interesting cases that will include the full spectrum of Dermatopathology, presented in the form of quiz.

The answer of the cases include related links and recent abstracts of articles.








Wednesday, November 30, 2011

Answer of Dermatopathology Case 108


Median Raphe Cyst

Visit: Dermatopathology Site
Visit: Pathology of Median Raphe Cyst

Abstract:
Median raphe cyst of the penis.Dermatol Online J. 2005 Dec 1;11(3):37.
Cysts of the median raphe are uncommon. We describe a 43-year-old man with an asymptomatic nodule on the glans penis. Excision of the lesion was performed followed by histological and immunohistochemical studies. Histopathological examination revealed a solitary unilocular cystic cavity in the corium, lined by a pseudostratified columnar epithelium, among which mucinous cells where identified. Hints of decapitation secretion occurred at the apex of the luminal layer. An immunohistochemical study using a standard avidin-biotin peroxidase method disclosed CK7 and CK13 reactivity in the columnar cells. Epithelial membrane antigen (EMA) and carcinoembryonic (CEA) antigen immunoreactivity occurred at the apical border of the luminal cells. No staining was obtained with anti-CK20, human milk fat globulin 1 (HMFG1) and anti- S100 protein. The study supports its histogenetic relationship with the urothelium.

Dermatopathology Case 108

Image1

Image 2

Image3

Image4


Case 108
A 38 year old male with a nodule on the glans penis.

Tuesday, November 29, 2011

Answer of Dermatopathology Case 107


Naevoid Melanoma

Visit: Dermatopathology Site
Visit: Pathology of Naevoid Melanoma

In general, common naevi are diagnosable at low power.
It is important to exclude the possibility of naevoid melanoma.
This is a rare variant that mimics benign naevi and is difficult to recognise.
The correct diagnosis is frequently made only after the patient has developed a metastasis.
At low power, naevoid melanoma may have a nodular architecture, and exhibit other features of a common banal naevus, including circumscription and at least relative symmetry.
Naevoid melanoma lacks the prominent junctional activity and pagetoid spread usually associated with superficial spreading melanoma.
Common intradermal naevus “matures” (there is an overall decrease in nest size and cellular and nuclear size with depth).
On low power examination, naevoid melanoma may appear to mature with depth, yet closer inspection reveals that the cells at the base of the lesions are similar in size to those of the superficial dermal component.
Only at higher power the distinguishing characteristics of naevoid melanoma can be appreciated.
These features include :
1) A monotonous population of small round cells with prominent nucleoli.
2) From a few to numerous mitoses any where in the lesion.
3) Other features that may be present include individual cell necrosis and atypical mitoses.

Dermatopathology Case 107

Image 1

Image 2

Image 3

Image 4

Image 5


Case 107

A 45 year old female with a pigmented lesion on the left side of the chest.
Diagnosis

Monday, November 28, 2011

Answer of Dermatopathology Case 106


Desmoplastic Spitz Naevus

Visit: Dermatopathology Site
Visit: Pathology of Desmoplastic Spitz Naevus
Visit: Pathology of Spitz Naevus

Abstract:

Desmoplastic Spitz nevus: a histopathological review and comparison with desmoplastic melanoma. Ann Dermatol Venereol. 2009 Oct;136(10):689-95.
INTRODUCTION: Desmoplastic Spitz nevus is a rare variant of spitzoid tumours characterized by dermal proliferation of large epitheliod and/or fusiform melanocytes within a desmoplastic stroma, comprising thick, eosinophilic collagen bundles. It occurs most frequently in young adults and children, and exhibits a predilection for the limbs. Histologically, this entity may be mistaken for cutaneous fibrous tumours or desmoplastic melanoma. To establish useful histological criteria for differential diagnosis of desmoplastic Spitz nevus, we conducted a retrospective study comparing data concerning the clinical, demographic and histological characteristics of desmoplastic Spitz nevus and desmoplastic melanoma.
PATIENTS AND METHODS: We reviewed the slides for 28 cases of desmoplastic Spitz nevus and for 13 cases of desmoplastic melanoma obtained from the files of Pinkus Dermatopathology Laboratory (Monroe, MI, USA) during the period 1993-2005.
RESULTS: Desmoplastic Spitz nevus was more common in women (sex ratio M/F=0.4) and younger patients (mean age: 28.2 years) whereas the mean age of patients with desmoplastic melanoma was significantly higher (mean age: 75 years). From a histopathological point of view, symmetry, circumscription, melanocytic maturation and involvement of adnexal structure were significantly more frequent in desmoplastic Spitz nevi. The presence of melanocytic junctional nests associated with discohesive cells, variations in size and shape of the nests, lentiginous melanocytic proliferation, actinic elastosis, pagetoid spread, dermal mitosis, perineural involvement and brisk inflammatory infiltrate were significantly more frequent in desmoplastic melanoma. No significant difference was found concerning epidermal hyperplasia, presence of Kamino bodies or moderate inflammatory infiltrate.
CONCLUSION: The combination of architectural and cytological features was useful in differentiating desmoplastic Spitz nevus from desmoplastic melanoma. A complete excision biopsy is mandatory in such tumors as the architectural criteria are necessary for a correct diagnosis.

Dermatopathology Case 106

Image1

Image2

Image2

Image3

Image4


Case 106

A 28 year old female with a reddish brown nodule on the left leg.
Diagnosis

Sunday, November 27, 2011

Answer of Dermatopathology Case 105

Immunostaining, staining reveals that the epithelial cells are positive for cytokeratin , estrogen receptor (ER) and progesterone receptor (PR).


PR (Progesterone Receptor):Positive


ER (Estrogen Receptor): Positive


Cytokeratin: Positive




Abstract:

Cutaneous ciliated cyst of the right lower leg. Pathol Int. 1999 Apr;49(4):354-7.
A 23-year-old Japanese woman with a cutaneous ciliated cyst on her right lower leg is reported. A subcutaneous cyst, measuring 2.5 cm in diameter with papillary projections into the lumen, was lined with ciliated cuboidal to columnar epithelia with partial stratification, histologically. These lining cells did not produce mucin. Immunohistochemically, the ciliated lining cells of the cyst were diffusely positive to epithelial membrane antigen and cytokeratin. In addition, positive immunoreaction with anti-desmin monoclonal antibody was observed in the body of the cilia. Less than 10% of the epithelial cells revealed positive immunoreaction to S-100 protein and estrogen receptor.

Dermatopathology Case 105

Image1

Image2

 

Case 105

A 38 year old female with a cystic lesion on the lower part of the left leg. The lesion is 2.5cm in diameter.


Diagnosis

Saturday, November 26, 2011

Answer of Dermatopathology Case 104

Allergic Granulomatosis (Churg-Strauss Syndrome)

Visit: Dermatopathology Site
Visit: Allergic Granulomatosis (Churg-Strauss Syndrome)
Visit: Pathology of Churg-Strauss Syndrome)

The three major microscopic features of Allergic Granulomatosis are:
1) Necrotizing vasculitis
2) Tissue infiltration by eosinophils
3) Extravascular granulomas
It should be noted that the 3 features mentioned above do not always coexist.

In Case No 104 there is small-vessel necrotizing vasculitis together with extensive tissue infiltration by eosinophils. No granulomas were present in the multiple sections taken. Hence in this case detailed clinical history played a very important role to reach the final diagnosis.

Dermatopathology Case 104

Image 1

Image2

Image 3

Image4

Image5

Image6

Case 104

A 42 year old female with history of asthma and allergic rhinitis. There is marked peripheral blood eosinophilia. Erythemous macules are present on the extremities. Biopsy from the skin lesion.

Diagnosis

Thursday, November 24, 2011

Answer of Dermatopathology Case 103

Infantile Hemangioma

Visit: Dermatopathology Site
Visit: Pathology of Infantile Hemangioma


Abstract:

Comparative study on pathology of noninvoluting congenital hemangioma and infantile hemangioma.Zhonghua Zheng Xing Wai Ke Za Zhi. 2011 May;27(3):178-81

OBJECTIVE: To distinguish noninvoluting congenital hemangioma (NICH) and infantile hemangioma (IH) by comparing the pathological structure and marker antigen expression.
METHODS: From Jan. 2005 to Aug. 2010, 39 paraffin-embedded samples, including 13 cases of NICH, 13 cases of proliferating IH and 13 cases of involuting IH, were collected from operation. Hematoxylin-eosin staining was used to observe the pathological structure. Immunohistochemical analysis was also performed to investigate the expression of Glut-1.
RESULTS: The lobules of capillaries were well-defined in NICH. The lobules were surrounded by abundant fibrous tissue. The capillaries were often large and integrity in NICH. There were few mitosis and apoptosis in endothelial cells and stromal cells in NICH. While in IH, the pathologic findings were totally different. Immunochemistry revealed that the Glut-1 was expressed in endothelial cells of IH, but not in NICH.
CONCLUSIONS: NICH has a steady histologic structure and low proliferation, while the endothelial cells in proliferative IH has a high proliferation. Glut-1 can be used as the reliable marker antigen for differential diagnosis of NICH and proliferative infantile hemangiomas.

Dermatopathology Case 103

Image1

Image2

Image3

Image4

Image5


Case 103

A 9 month old child with a reddish nodule on the forehead.


Wednesday, November 23, 2011

Answer of Dermatopathology Case 102

Acrodermatitis Chronica Atrophicans

Visit: Dermatopathology Site
Visit: Pathology of Acrodermatitis Chronica Atrophicans

There is superficial and deep chronic inflammatory cellular infiltrate in the dermis.
It is moderately heavy and composed mainly of lymphocytes together with histiocytes and plasma cells.
There is telangiectasia and the cellular infiltrate is prominent around the blood vessels.
Inflammatory cells are also present around the adnexae.
Thickened collagen bundles are haphazardly present in the upper half of the dermis.
There is some atrophy of the dermis and of the subcutis. The epidermis also shows variable atrophy with loss of rete pegs.

Dermatopathology Case 102

Image1

Image2

Image3

Image4

Image5


Case 102


A 68 year old male with ill-defined erythema on the extensor surface of the lower end of the right leg extending to the dorsum of the foot.There is associated wrinkling of the skin.


Monday, November 21, 2011

Dermatopathology Case Index: Case 81 to Case 100


Dermatopathology Quiz - Case Index

Case 81 = Langerhans Cell Histiocytosis

Case 82 = Rheumatoid Nodule

Case 83 = Gouty Tophus

Case 84 = Polymorphous Light Eruption

Case 85 = Graft-Versus-Host Disease

Case 86 = Pilar Sheath Acanthoma

Case 87 = Angiokeratoma

Case 88 = Neurothekeoma (Nerve Sheath Myxoma)

Case 89 = Digital Mucous Cyst

Case 90 = Lichen Simplex Chronicus

Case 91 = Proliferating Trichilemmal Cyst (Pilar Tumour)

Case 92 = Subcorneal Pustular Dermatosis (Sneddon-Wilkinson disease)

Case 93 = Urticaria Pigmentosa

Case 94 = Hypertrophic Lichen Planus

Case 95 = Papillary Eccrine Adenoma

Case 96 = Primary Cutaneous Anaplastic Large Cell Lymphoma

Case 97 = Mycosis Fungoides-associated Follicular Mucinosis

Case 98 = Epithelioid Hemangioendothelioma

Case 99 = Kaposiform Hemangioendothelioma

Case 100 = Retiform Hemangioendothelioma

Answer of Dermatopathology Case 101

Microvenular Hemangioma


Visit: Dermatopathology Site
Visit: Pathology of Microvenular Hemangioma

Abstract:

Microvenular hemangioma. Ann Dermatol Venereol. 2004 May;131(5):475-7.
INTRODUCTION:
Microvenular hemangioma belongs to the group of acquired vascular tumors. It is important to differentiate such lesions because of their prognostic and nosologic consequences. We report a case of microvenular hemangioma.
CASE REPORT:
A 31 year-old man presented with a 3 cm erythematous and asymptomatic nodule of the abdomen, which had grown for 2 months. Histopathology showed the irregular dermal proliferation of small vessels, composed of capillaries and venules, without atypia. No relapse was noted 6 months after complete exeresis.
DISCUSSION:
Microvenular hemangioma is a recently described vascular tumor. The first three cases were reported in 1989, with the denomination of "microcapillar hemangioma". Twenty-one further cases have been reported since 1991. We discuss the typical clinical and histological characteristics of this lesion and present criteria permitting the differential diagnosis with other vascular neoplasms. Dermatologists should be aware of this lesion, notably for the differential diagnosis with early onset Kaposi's disease.

Dermatopathology Case 101

Image 1

Image2

Image3

Image4

Image5

Case 101

A solitary erythematous nodule on the right forearm of a 45 year old woman.

Diagnosis

Sunday, November 20, 2011

Answer of Dermatopathology Case 100

Retiform Hemangioendothelioma

Visit: Dermatopathology Site
Visit: Pathology of Hemangioendothelioma

Abstract:

Retiform haemangioendothelioma: a case report.Ann Pathol. 2009;29(6):491-4.
Retiform haemangioendothelioma is a locally aggressive, very rarely metastasizing vascular lesion. Histologically, it is characterized by distinctive arborizing blood vessels resembling "rete testis" and lined by endothelial cells with characteristic hobnail morphology. We present an additional case, in the leg of a 64-year-old patient. We discuss the classification of hemangioendotheliomas. The term hemangioendothelioma should be restricted to vascular tumours of "intermediate malignancy" but has been used to designate tumours with variable histological features and clinical behaviour. Spindle cell hemangio(endothelio)ma is currently regarded as a benign reactive lesion. Kaposiform hemangioendothelioma is potentially lethal due to consumption coagulopathy but no metastasizing case has been reported. Epithelioid hemangioendothelioma is associated with a significant metastatic risk and has been included in the category of malignant vascular tumors. The vascular lesions fulfilling the strict definition of hemangioendothelioma include retiform hemangioendothelioma, papillary intralymphatic
angioendothelioma"Dabska's tumor",composite hemangioendothelioma and perhaps the controversial polymorphic hemangioendothelioma.

A case of retiform-hemangioendothelioma with unusual presentation and aggressive clinical features.Int J Clin Exp Pathol. 2010 May 12;3(5):528-33.
Retiform hemangioendothelioma (RH) is an extremely rare low-grade angiosarcoma mainly involving the skin and subcutaneous tissue. Clinically patients often present with an asymptomatic slow-growing solitary nodular or plaque-like lesion. RH is characterized by frequent local recurrences but a very low metastatic rate. Here we reported a case of RH in a 61-year-old Chinese woman who presented with a rapid growing cutaneous plaque-like lesion on her right scalp, followed by another lesion behind the right ear. The lesions were associated with paroxysmal sharp needle-stabbing like headache. She underwent wide excision and skin engraftment. Three months post surgery, she experienced tumor recurrence, and died 9 months after the initial diagnosis.

Retiform hemangioendothelioma developed on the site of an earlier cystic lymphangioma in a six-year-old girl. Am J Dermatopathol. 2011 Oct;33(7):e84-7.
Retiform hemangioendothelioma (RH) is a rare low-grade malignancy angiosarcoma, with a high rate of local recurrence and a low metastatic risk. A 6 year-old girl with a large cervical cystic lymphangioma diagnosed by ultrasound and Doppler ultrasound, which showed a large multiloculated anechoic cyst with no flow. The lymphangioma was treated with injections of Picibanil (OK-432). The tumor regressed, but after a year, she developed a poorly limited infiltrated plaque spreading out regularly over her chest, back, and shoulder. The biopsy showed a poorly limited dermal and subcutaneous vascular proliferation composed of elongated arborising vessels lined with ovoid endothelial cells in a hobnail pattern. In addition, the deep part of the lesion showed typical features of a papillary intralymphatic angioendothelioma pattern (PILA) or Dabska tumor. The endothelial cells strongly expressed podoplanin (D2-40). A diagnosis of RH with focal areas of PILA was reached. The girl died 8 months after surgery of hypovolemic shock in a context of diffuse lymphangiomatosis with pulmonary localization. To our knowledge, RH has hardly ever been described in children. This entity exhibits a continuum with the PILA, sharing not only morphological and immunohistochemical similarities but also its ability to develop in a context of a vascular anomaly, particularly a lymphangioma. The role of Picibanil in the development of this tumor can be discussed.

A rare angiosarcoma: retiform haemangioendothelioma.J Laryngol Otol. 2011 Sep 5:1-3.
Objective:We report the case of a rare angiosarcoma, retiform haemangioendothelioma, in an 18-year-old young man, which presented as a recurrent ulcerating lesion of the left pinna.
Method:Case report and literature review of retiform haemangioendothelioma. This is a low grade angiosarcoma with a high local recurrence rate and low metastasis rate, and was first described in 1994 by Calonje et al.
Results: This patient represents only the third report of lymph node metastasis in a case of retiform haemangioendothelioma. To date, 31 cases of the tumour have been reported. Histological diagnosis of this group of vascular neoplasms can be challenging, as their histopathological appearance is intermediate between haemangioma and angiosarcoma. Conclusion:Surgical excision remains the primary treatment modality, with adjuvant radiotherapy recommended in patients with large tumour size, local recurrence and lymph node metastasis, as seen in this case.

Retiform hemangioendothelioma: presentation of a case expressing D2-40.J Cutan Pathol. 2009 Sep;36(9):987-90.
Retiform hemangioendothelioma (RH) is a low-grade angiosarcoma with low metastatic risk, usually occurring as a single lesion on the trunk or extremity in middle-aged adults.
Histopathology shows a distinctive pattern with arborizing blood vessels arranged in a retiform pattern (similar to rete testis tissue) and focal papillae with fibrosclerotic (hyaline) cores. The blood vessels are lined by comparatively monomorphic endothelial cells, frequently presenting a hobnail pattern. We report a case of RH presenting as an indolent brownish plaque on the back of a 17-year-old male. Surgical resection and sentinel lymph node biopsy showed no evidence of metastasis. In contrast to the recent literature, this case of RH showed positivity for D2-40, a marker of lymphatic endothelium. We also report ultrastructural findings for this case of RH.

Dermatopathology Case 100

Image 1

Image 2

Image 3

Image4

Case 100


A 28 year old male with an indolent brownish plaque on the right lower limb.


Saturday, November 19, 2011

Answer of Dermatopathology Case 99

Kaposiform Hemangioendothelioma

Visit: Dermatopathology Site
Visit: Pathology of Hemangioendothelioma

Abstract:

Successful treatment of Kasabach-Merritt syndrome arising from kaposiform hemangioendothelioma by systemic corticosteroid therapy and surgery.Int J Clin Oncol. 2011 Sep 28.
Kasabach-Merritt syndrome is a rare type of vascular tumor with aggressive behavior in association with thrombocytopenia and consumptive coagulopathy. A standard guideline has not been established to date. A 7-day-old male infant with Kasabach-Merritt syndrome arising from kaposiform hemangioendothelioma was successfully treated with systemic corticosteroid and surgery. Systemic corticosteroid including methylprednisolone was injected intravenously followed by an intralesional injection of compound betamethasone. This approach brought about an excellent response after the first treatment which was maintained long enough to provide us with an opportunity to excise the tumor. Systemic corticosteroid and surgery may be considered an option for Kasabach-Merritt syndrome, although well-designed studies are needed to quantify the benefits and risks of this treatment

Prox1 Transcription Factor as a Marker for Vascular Tumors-Evaluation of 314 Vascular Endothelial and 1086 Nonvascular Tumors.Am J Surg Pathol. 2011 Nov 3
Prox1, a transcription factor important in the regulation and maintenance of the lymphatic endothelial phenotype, is consistently expressed in lymphangiomas and Kaposi sarcoma and has also been reported in Kaposiform hemangioendothelioma. However, information on its distribution in vascular tumors, such as angiosarcoma, is limited. In this study, we examined selected normal tissues and 314 vascular endothelial and 1086 nonvascular tumors to get an insight into the biology of these tumors and on potential diagnostic use of Prox1 as an immunohistochemical marker. In adult tissues, Prox1 was essentially restricted to lymphatic endothelia, with expression in subsets of pancreatic and gastrointestinal epithelia. However, it was also detected in embryonic liver and heart. Prox1 was consistently expressed in lymphangiomas, venous hemangiomas, Kaposi sarcoma, in endothelia of spindle cell hemangioma, Kaposiform hemangioendothelioma, and retiform hemangioendothelioma, and in half of epithelioid hemangioendotheliomas. It was present in most cutaneous angiosarcomas from different sites but was less commonly expressed in deep soft tissue and visceral angiosarcomas. In contrast, Prox1 was generally absent in capillary and cavernous hemangiomas. In positive hemangiomas and angiosarcomas it was coexpressed with podoplanin, another marker of the lymphatic endothelial phenotype. There was an inverse correlation with CD34 expression. The expression in mesenchymal nonendothelial neoplasm was limited. Prox1 was detected in 5 of 27 synovial sarcomas, specifically in the epithelia of biphasic tumors. Four of 16 Ewing sarcomas and 5 of 15 paragangliomas were also positive. All melanomas and undifferentiated sarcomas were negative. Among epithelial neoplasms, Prox1 was detected in 18 of 38 colonic carcinomas and 10 of 15 cholangiocarcinomas and in a minority of pulmonary, prostatic, and endometrial adenocarcinomas. The common Prox1 expression in angiosarcoma and its rare presence in nonvascular mesenchymal tumors make this marker suitable for the diagnosis of angiosarcoma and Kaposi sarcoma. However, the presence of Prox1 in some malignant epithelial tumors necessitates caution in applying Prox1 as a marker for vascular tumors. Common Prox1 expression in angiosarcoma may reflect the lymphatic endothelial phenotype in these tumors. Its patterns of expression in hemangiomas and angiosarcoma may be diagnostically useful and offer a new parameter in the biological classification of vascular tumors.

Usefulness of D2-40 immunohistochemistry for differentiation between kaposiform hemangioendothelioma and tufted angioma.J Cutan Pathol. 2006 Jul;33(7):492-7.
BACKGROUND: Recent investigations have demonstrated the utility of the monoclonal antibody D2-40 as a marker for lymphatic endothelium. D2-40 can be used on formalin-fixed and paraffin-embedded materials. Our objective was to elucidate, using D2-40 immunohistochemistry, the differences among capillary hemangiomas, and especially between kaposiform hemangioendothelioma (KHE) and tufted angioma (TA). We studied four cases of KHE, nine cases of TA, and 31 cases of other vascular tumors. Antibodies against CD31, CD34, factor VIII-related antigen, and GLUT1 were also applied.
RESULTS: In KHE, D2-40 was markedly reactive for three and partially for one of four cases in the peripheral area of Kaposi's sarcoma-like proliferative capillaries and negative in the surrounding dilated vessels. In TA, D2-40 was partially positive in the surrounding dilated vessels and negative in cannonball-like proliferative capillaries.
CONCLUSIONS: Our results suggest that D2-40 is a useful antibody for immunohistochemical discrimination between KHE and TA. In addition, the difference of immunostaining pattern of D2-40 is limited to the peripheral area of capillary proliferation and surrounding dilated vessels; therefore, it is suggested that KHE and TA may reflect different stages in the evolution of a single entity. Namely, they may originate from stem cells possessing the characteristics of both lymphatic and blood vessel endothelial lineages.

Update on vascular tumors of infancy.Curr Opin Pediatr. 2010 Aug;22(4):432-7.
PURPOSE OF REVIEW: Advances have been made in the pathogenesis, diagnosis and management of vascular tumors of infancy in the past year. Propranolol therapy for infantile hemangiomas (IH) is now being used widely, and case reports, series, and adverse effects are reviewed. Kaposiform hemangioendothelioma and tufted angioma are less common than IH but more often associated with coagulopathy (Kasabach-Merritt phenomenon).
RECENT FINDINGS: Recent work suggests that stem cells, mediated by the Notch signaling pathway, may become proliferating endothelial cells that comprise IH. Large, segmental IH are more likely to develop complications that can include life-threatening bleeds; however, solitary large IH do not appear to increase the risk of hepatic IH. Segmental IH may herald underlying structural anomalies of the brain, cerebral, and cardiac vessels (PHACE syndrome--Posterior fossa defects, Hemangiomas, Arterial anomalies, Cardiac defects and Coarctation of the aorta, Eye anomalies), and new criteria aid in diagnosis. Propranolol therapy is effective in life-threatening IH and appears to stop growth and hasten involution in proliferative and plateau phase IH. Adverse effects include bradycardia, hypotension, hypoglycemia, and bronchospasm. A recent review of kaposiform hemangioendothelioma finds that an associated coagulopathy (Kasabach-Merritt phenomenon) occurs in 72%.
SUMMARY: Propranolol appears to be tremendously efficacious with fewer side effects than systemic corticosteroids, but its proper place in the therapeutic algorithm for IH and other vascular tumors awaits controlled study.

Dermatopathology Case 99

Image1

Image2

Image3

Image4

Image5


Case 99

A reddish blue nodule on the left upper arm of a 3 year old child.