David Elpern MD, Williamstown, Massachusetts, USA
on September 7, 2007
Kudos to Dr. Dintiman and her colleague for an extraordinary
case presentation. Lucidly presented and challenging. I have
seen three cases of interstitial granulomatous dermatitis (IGD)
in the past year and have been struck by the fact that they
looked quite dissimilar to each other. This may be a histopathologic
diagnosis, like sarcoidosis which has protean clinical manifestations.
The cause of IGD, like that of sarcoidal reactions of the skin
may be varied, too. My cases were idiopathic, although we suspected
drug in at least one. The process in my cases seemed to wax
and wane. Clinically, I agree this looked like xanthoma disseminatum,
but the path did not support that. It would be instructive to
have a few dermatopathologists weigh in on this case.
Many case of IGD in the literature have been associated with
arthritis. What was the rheumatologist's working dx that led
to Mtx therapy?
Nick Mousdicas MD, Clinical Associate Professor, Department
of Dermatology, Indiana University, Indianopolis, Indiana, USA
on September 7, 2007
I would consider doing appropriate age and sex cancer screening
and strongly consider stopping whichever of the listed drugs
that had been prescribed prior to the onset of the dermatosis.
I have been burned too many a time ignoring prescribed drugs
as a cause of unusual skin presentations.
Khalid Al Aboud M.D., Medical Director, Makkah, Saudi
Arabia on September 7, 2007
What about leprosy ?Mycosis fungoids? What about CBC , and
peripheral blood smear? Is there any atypical cell?
Omid Zargari MD, Rasht, Iran on September
I think this is a case of disseminated granuloma annulare.
Immunohistochemical staining (CD68/PGM1) may aid in making a
definite diagnosis. A short course of cyclosporine might be
helpful in treating this man. Nice case, thanks for sharing.
Bushan Kumar MD, Former Head of Dermatology, Postgraduate
Institute of Medical Education & Research, Chandigarh, India
on September 7, 2009
Langerhans cell histiocytosis. It will heal of its own but
it will take many months. No treatment is required – slight
response to methotrexate is expected
Stephen Glinick MD, Clinical Assoc Prof, Brown University,Providence,
Rhode Island, USA on September 8, 2007
Consider Multicentric Reticulocytic Histiocytosis given the
arthritis, leonine facies and consistent histologic findings.
Goh Chee Leok MD FRCP, Professor, National Skin Centre,
Singapore on September 9, 2007
An interesting case indeed. The case will have to depend heavily
on the dermpath report. They seem to have several differential
diagnoses. The dermatopath needs to do some immunohistochemistry
study to ascertain the cell type.
I hope they have excluded leprosy - histoid leprosy with the
relevant Fite stain. I would seriously remove/replace the drugs
that he is on to exclude a drug eruption.
If it is disseminated GA, phototherapy has been reported to
be helpful (provided the lesions are not photosensitive).
J Dintiman M.D., Fairfax, VA, USA on
Feb 26, 2008
He has been on methotrexate 15mg a week for 1 year and a little
dermazinc . Methotrexate given to him by rheumatologist. Still
diagnosis of skin unclear but cleared.