65 yo woman with erythematous eruptions of thighs

presented by

Haimish Dunwoodie MD

Skidgate, Queen Charlotte Island, B.C., Canada

on November 10, 2011

Locum Tenens GP, Hecate Straits Clinic, Skidgate, Queen Charlotte Islands, B.C., Canada

 
Abstract

65 yo woman with erythematous eruption of thighs

Patient

An artist in rural British Columbia

Duration
one year
Distribution
thighs
Clinical Course

Sirs:  I am spending a few years doing locums in rural Canadian outports, having just retired from practice in Moncton, NB.  Recently, I saw a patient who may benefit from your combined expertise.

The patient, a 65 yo artist in Skidgate, complained about a progressive, asymptomatic erythematous process which began symmetrically on her thighs about a year ago and is slowly spreading centrifugally.  She takes no meds other than low dose fluoxetine.

O/E: The lesions are macular, subtle, and of a uniform pink colour. (photos).  Otherwise, her general skin exam was unremarkable.

Images

Laboratory Data

 

Histopathology

Because of my uncertainty,  I performed a punch biopsy.  The histological findings were subtle for our pathologists and a colleague in the States kindly facilitated an opinion from the SkinPath laboratory at Boston University which is associated with Virtual Grand Rounds.

Pathology: There are ectatic congested capillaries and a superficial and interstitial lymphohistiocytic infiltrate with a mild increase in mast cells. Immunoperoxidase staining with CS117 is positive, as is special staining with chloracetate esterase.  These findings support the diagnosis of telangiectasia macularis eruptive perstans (TMEP)

Histopath pictures courtesy of Marjan Mirzabeigi, MD Assistant Professor, Director of Resident and International Dermatopathology Training, Boston Medical Center, Department of Dermatology, Dermatopathology  Section, Boston, MA, USA

H&E Low power

H&E high power

Chloracetate esterase stain (red). This stain along with CD117 (brown) would highlight mast cells in both perivascular and interstitial pattern.

Diagnosis

Presumptive Diagnosiis:  Telangiectasia Macularis Eruptiva Perstans

Reason for presentation

I have arranged for our patient to have a CBC and a chemistry profile.  At the time being, I am not recommending any further tests or treatments pending more opinions.  PUVA is out of the question in the Charlottes and the patient is loath to travel to Vancouver or Victoria for that.

References

 

Keywords

TMEP, mastocytosis

Comments from Faculty and Members

Khalid Al Aboud MD, Consultant Dermatologist, King Faisal Hospital , Makkah,
Saudi Arabia
on November 10, 2011

The possible diagnoses in this case are many including a drug reaction.
However, I just want to raise the possibility of Scurvy (vitamine C def.) specially in this age. I would advice for looking carefully to the other cutaneous nd mucosl changes for scurvy. Blood tests, and you may consider starting her on Vit C (Redoxon) 1 gm tablet  daily and see the response.

Malcolm Lane-Brown MD, Consultant Dermatologist, Sydney, NSW, Australia on November 10, 2011

Well presented case of TMEP. Difficult to treat. Rule out systemic mast cell disease (serum tryptase). NBUVB as good as PUVA. Laser works. Reassure.

Meenakshi Mohanram MD, Assistant Professor of Dermatology, Chettinad Medical College, Kancheepuram, Tamil Nadu, India on November 12, 2011

Very rare and interesting case. Have you done serum tryptase level? I would recommend a peripheral smear & Ultrasound abdomen. Why not try a short tapering course of short acting steroids?

Abdullah Mancy MD, FICMS, Dermatologist, Ramadi, Iraq on November 21, 2011

TMEP, despite its long descriptive term, there is little or no telangectasia. Darier's sign may not be demonstrated because the number of mast cells in the skin are not greatly increased. At this age it is better to assess systemic extention of the disease by bone marrow assessment. The patient can be followed up by serum tryptase level and complete blood count at regular intervals. Regarding its treatment, it is not easy when there is systemic involvement. Drug eruption and capillaritis can be excluded.

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