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MyDermatology-Bolognia > Pathology-Inflammatory Reaction Patterns(KVK) > Flashcards

Pathology-Inflammatory Reaction Patterns(KVK) Flashcards

1
Q

When working up vesiculobullous conditions, what 2 biopsies are taken, from where, and what media?

A
  1. Lesional in formalin for H+E

2. Perilesional, within 1 cm of lesion in michels for DIF

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2
Q

What are the H+e findings of pemphigus vulgaris, where is the split?

A
  1. Suprabasilar acantholysis with intraepidermal split
  2. Tombstoning of remaining basal keratinocytes
  3. Dermal papillae resemble “villae”
  4. Process extends into follicular structures
  5. Limmited spongiosis
  6. Mild mixed dermal inflammation with some eosinophilic component
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3
Q

What are the DIF findings in pemphigus vulgaris

A

Intercellular keratinocyte junctions, often lower epidermis

IgG and C3

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4
Q

What level is the split for pemphigus foliaceous?

A

Subcorneal/intragranular

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5
Q

What does pathology for paraneoplastic pemphgius show, comparatively to PV

A

Pemphigus features + interface dermatitis

DIF stains intercellular keratinocytes junctions + Basement membrane zone

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6
Q

Pathology for H+E for Hailey-Hailey vs. PV

A

Acantholysis extends to mid upper epidermis (vs. Suprabasilar)
No follicular involvement
Negative DIF
Fam hx

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7
Q

Pathology for Dariers and Grovers vs. PV

A

Acantholysis with prominent dyskeratosis

*Grovers-often other rxn patterns seen

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8
Q

What is pathological ddx for PV?

A 
Pemphigus variants (foliacous, paraneoplastic)
Hailey-Hailey
Darier
Grover
HSV
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9
Q

What are the H+E findings for BP? What is the split level?

A
  1. Subepidermal blister
  2. Blister cavity tends to contain EOS
  3. Variable inflammation
    - moderately dense lymphocytic and EOSINOPHILIC inflammatory infiltraet in superficial dermis +- deeper extension
    - may be sparse inflammation also
    - few lymphocytes and eos in edematous superficial dermis (urticaria like)
    - some cases may be more neutrophilic predominent
  4. Eosinophilic tagging at DEJ +- eosinophilic spongiosis
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10
Q

DIF findings of BP

A

Linear deposits of IgG and C3 and basement membrane zone

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11
Q

In BP, what side of blister fluoresces on salt split skin

A

Roof/epidermal side

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12
Q

What layer does salt split skin break at?

A

Lamina lucida of BMZ

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13
Q

What are the layers of BMZ

A

Basal keratinocyte
Hemi-desomosome
Lamina lucida (BPAG2, Integrin aplpha and beta)
Lamina densa (Laminin 5, Type IV collagen)
Sublamina Densa (Type VII collagen, elastin, Collagen I and III)

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14
Q

Name 2 fungal stains

A

PAS-D (diastase)-stains purple

GMS (dirtier)

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15
Q

Name 3 stains for mast cells

A
  1. Toludine blue
  2. Giemsa
  3. Leder
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16
Q

Name a stain for melanin

A

Fontana

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17
Q

Name 2 IHC tests for mast cells

A

CD117

Mast cell tryptase

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18
Q

What 2 stains would you order for suspected CTD

A
  1. Colloidal iron for mucin

2. PAS-D for BMZ

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19
Q

Name 1 stain for lieshmeniasis

A

Giemsea

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20
Q

2 stains for mycobacteria

A
  1. Zhiel Nielson for AFB-best for TB

2. Firth-best for atypicals or leprosy (modified ZN)

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21
Q

2 stains for mucin

A

Hales colloidal iron

Aclian blue

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22
Q

Stain for hemosiderin

A

PPB

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23
Q

3 stains for amyloid

A

Congo red
Crystal violet
Thioflavin T

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24
Q

`

A
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25
Q

BP vs. Cicatricial pemphigoid: differences on H+E

A
  • scarring later on
  • mucous membranes, sometimes skin involvement
  • adnexal extension
  • neutrophils >eos
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26
Q

BP vs. Herpes gestationis

A
  • history-pregnant female
  • linear BMZ staining for C3 in all cases, fewer positive for IgG
  • Occasional necrotic keratinocytes at DEJ
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27
Q

BP vs. EBA? How to tell on path

A

DIF —> salt split skin localizes to FLOOR, BP to roof

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28
Q

Bullous insect bite vs. BP

A

Inflammation more prominent with deeper extension and wedge shaped appearance

  • spongiotic intraepidermal AND subepidermal vesicles from edema (tethering by fine goassame strands of collagen > true split
  • negative DIF
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29
Q

DDX BP on H+E

A 
Cicatricial Pemphigoid
Insect bite
Bullous drug 
DH
EBA 
Urticaria
Linear IgA
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30
Q 
Main inflammatory infiltrates in: 
PV
BP
DH
Linear IgA
A

PV-Eos + lymph
BP-Eos + lymph
Linear IgA-Neut
DH-neutrophils

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31
Q

H+E findings DH

A

Neutrophils localize at tips of dermal papillae
Subepidermal split —> often small, localized to tips dermal papillae
Early lesions—> neutrophilic tagging at DEJ w/ nuclear dust
Superficial +- deep perivascular and interstitial inflammation: Neut>lymph+eos

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32
Q

DIF for DH?

A

GRanular IgA and C3 at tips of dermal papillae +- BMZ

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33
Q

Pathology for Linear IgA BD

A

Large subepidermal blisters with DIFFUSE SUPERFICIAL DERMAL NEUTROPHILS

DIF shows linear staining for IgA at BMZ

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34
Q

What is included in DDx for perivascular dermatitis pattern?

A 
Urticaria 
Dermal hypersensitivity rxns to BUGS, DRUGS (bug bite, drug rxn)
Gyrate erythemas 
Urticarial vasculitis 
Normal skin 
UP/TMEP
LyP, other cutaneous lymphoproliferative disorders 
PMLE, Sweets
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35
Q

What are the major inflammatory reaction patterns

A
  1. Epidermal
    - spongiotic
    - psoriasiform
    - interface
    - vesiculobullous
  2. Dermal
    - perivascular
    - Nodular and diffuse infiltrates (granulomatous)
    - vasculitis/vasculopathy
    - skin appendegeal (alopecia, folliculitis,)
    - panniculitis
36
Q

What 5 things to consider when looking at perivascular dermatitis

A

Distribution (lichenoid, perivascular, periadnexal, interstial-ie in between collagen away from vessels)

Depth: superficial, deep, both

Density: sparse (e.g urticaria) vs. Dense (arthropod bite)

Compositions/type of infilrate: lymph, eos, neut, plasma cells, histiocytes, granulomatous, mast cells

Degree of perivascular “cuffing”—> tight suggesting more gyrate erythema vs. Urticaria tends to be looser

*Other changes like epidermal change, stromal alteration, vascular injury

37
Q

Name 5 pathological features of urticaria

A
  1. Reticular dermal edema (increased space between collagen bundles, more clear)
  2. Dilated BV
  3. Sparse to MILD mixed superficial +- deep perivascular inflammation with lymphocytes, eos, neuts, and mast cells
  4. Interstitial granulocyte
  5. Margination of neutrophils against vessel wall lumnes

*May be increased neutrohpilic component = neutrophilic urticaria (tend to be phyiscal or longer lasting lesions)

38
Q

DDX for urticaria on pathology-name 6

A
  1. Dermal hypersensitivity rxn (drugs, bugs)
    - usually some epidermal change, more inflammation, less dermal edema
  2. Gyrate erythema
    - More intense inflammation and tight cuffing
  3. Urticarial vasculitis
    - More like neutrophilic urticaria, vasculitis
  4. Normal skin
  5. UP or TMEP
    - INCREASED MAST CELLS
    - *mast cell stains
39
Q

Name 7 findings on H+e of arthropod assault

A
  1. Dense wedge shaped perivascular inflammation, almost nodular with sup and deep inflammation
  2. Small activate lymphocytes + interstial EOS, minimal other cell types
  3. Can see flame figures, lymphoid nodules, vascular reaction
  4. Small focus epiderma/dermal necrosis
  5. Limited focus sponiosis and spongiotic vesicle
  6. Can have MASSSIVE superficial papullar dermal edema= both sup and intraepidermal vesicles, tether with collagen
  7. Arthropod remnants
  8. Scratching findings

*May need more levels

40
Q

Name 2 diseases (other than arthropod bite) withmassive papillary dermal edema

A

Sweets
PMLE
*usually no eos

41
Q

DDx for granulomatous dermatitis-What are the 7 main categories

A
  1. Sarcoidal
  2. Tuberculoid
  3. Suppurative
  4. Foreign body
  5. Palisading
  6. Elastolytic
  7. Interstitial granulomaous inflammation
42
Q

DDx for sarcoidal pattern granulomas

A

Sarcoid
Infection
Other

43
Q

DDX for tuberculoid granuloma pattern

A

Rosacea
Cuaneous chrons
Infection—> TB, leprosy, late syphillis, leish

44
Q

DDX for suppurative granulomatous

A

Infection-deep fungal, atypical mycobacteria, other bacteria
Ruptured cyst/follicle

45
Q

DDx for foreign body granuloma

A

Ruptured cyst/follicle
Tattoo
Cosmetics
Other stuff-sutures

46
Q

DDX-name 3 things for ddx of palisading granulom

A

GA
Necrobiosis lipoidica
Rheumatoid nodule
*Palisading granulomatous dermatitis ?

47
Q

DDX-name 3 things on ddx for interstial granulomatous inflammation

A

Interstitial GA
Interstitial granulomatous drug rxn
Interstitial granulomatous dermatitis/rheumatoid papules

48
Q

What is a granuloma

A

Focus of histiocytes

*GRanulmatous infiltrates is generally where histiocytes are predominant cell =abundant pale cytoplasm

49
Q

What is the branch point after granulomas in terms of classification

A

Naked/sarcoidal granuloma=few or no lymphocytes surrounding the macrophages

Tuberculoid granuloma= many lymphocytes surrounding

Palisading= infiltrate forms around central area of degenerating connective tissue or necrosis

Foreign body =surrounds foreign body

Suppurative =many surrounding neutrophils

Elastolytic= granuloma in setting sun damaged skin

Interstitial=

50
Q

How do we classify/appraoch nodular/diffuse infiltrates? What is defining feature?

A

Little to no epidermal involvement
Diffuse or localized aggreagations (nodular) of cell infiltrates

7 categories based on cell infiltrating:

  1. Eosinophil
  2. Mast cell
  3. Neutrohpilic
  4. Suppurative (robust neutrophilic)
  5. Lymphoplasmacytic
  6. Diffuse histiocytoses
  7. Granulomatous—> sarcoidal, tuberculoid, foreign body, palisading, interstitial, elastolytic, suppurative
51
Q

What are the 2 histopathological types of GA? What do they each show on path?

A
  1. Interstitial
    - busy dermis with increased interstitial histiocytes and stellate fibroblasts
    - rare giant cells
    - perivascular lymphocytes
    - Increased dermal mucin
  2. Palisading pattern
    - Central zone of degenerate altered collagena nd mucin in ddermis=blue grauloma
    - surrounding central zone are palisading giant cells and histiocytes
52
Q

What is on DDX for GA (path wise i.e. for increased interstitial histiocytes)

A
  1. Other palisading granulomatous dermatoses:
    - Necrbiosis lipoidica diabeticorum
    - Rheumatoid nodule
    - palisaded neutrophilic and granulamtous dermitis or rheumatoid papules
    - infectious palisaded granuloma
  2. Interstitial granulomatous drug reaction
  3. Actinic granuloma (DISTINCT from GA on sun damaged skin)
  4. Granulomatous MF (clinically MF, MF in epidermis, but intestitium shows GA or sarcoid like granulomas)
53
Q

Name 4 palisaded granulomatous dermatoses

A

Necrobiosis lipoidica diabeticorum
Palisaded neutrophilic and granulamtous dermaittis
Rheumatoid nodule
Infectious palisaded granuloma

54
Q

Pathology for NLD?

A

Dermis adjacent to the palisaded granuloma is altered (vs. Normal in GA)
Increased collagen degeneration and fibrosis
No central mucin=red granuloma
Palisaded granulomata arranged as horizontally oriented tiers (gA-round to oval shaped)
Prominent plasma cells
“Dirtier” component, may be vasculitic

55
Q

Path for Rheumatoid nodule

A

Palisading granuloma surrounds zone of eosininophi;lic fibrinoid necrosis
May see residual vlood vessel/vasculitic process in centre with occasional neutrophil
No central mucin

56
Q

What is the pathological finding in palisaded neutrophilic granulomatous dermatitis

A

GA with central vasculitis and lots of neutrophils

57
Q

Path for infectious palisaded granuloma

A

Central necrosis with abundant neutrophils

58
Q

What is pathological findings of erythrotelangiectatic rosacea?

A

Sun damaged skin
Increased telengiectatic vessels
Mild derma edema
Mild perivascular, perifollicular and periinfundibular infiltrate, superficial to mid dermis
Lymph + histio + plasma cells seen
DEmodex mites in follicles
Epidermis normal or non specific acanthosis/scale
Low level follicular inflammation or spongiosis

59
Q

What are the path findings of acne rosacea with papulopustules predominantly

A

Compared to erythrotelengiectatic form:

  • more inflammation
  • lymphochistiocytic folliculitis
  • may see neutrophils
  • may see increased perifollicular histiocyes, poorly formed perifullicular granulomata—> well formed perifullicular tuberculoid granulomata =folliculocentric poorly formed granulomata
  • granulomata often poorly formed, non necrotizing, may be suppurative
60
Q

Name the single feature needed for vasculitis dx

A

Fibrinoid necrosis

61
Q

What is the progression of cellular infiltrate in vasculitis over tiem

A

Neutrophilic—> Mixed neuts and lymphocytes —> less inflammation, more lymphocytic and histiocytic

62
Q

Name 8 findings in LCV on H/E

A 
Fibrinoid necrosis *
Nuclear dust
Extrav RBC
Perivascular fibrin deposition
Endothelial cell swelling and vessel wall edema
Occlusion by fibrin thrombi 
Neutrophilic perivascular infiltrate
DIF may show granular staining in vesseles for IG and/or C3

*Epidermis usually normal, may blister from epidemia, if pustules in epidermis think infection, if vacuolar interface change think CTD, drug reaction

63
Q

What 2 biopsies do you want for vasculitis/

A
  1. Lesional palpable purpuric lesion, <48 hrs for H/E
  2. DIF also lesional, early erythematous or purpuric lesion
    * 3-4 mm punch
64
Q

What are the immune complex mediated LCV?

A 
IgA vasculitis
Urticarial vasculitis
AI CTD 
Cryoglbulinemia 
Serum sickness 
*Skin only
—> IgG/IgM
65
Q

Name 4 things on DDx for LCV on path?

A
  1. Vasculitis secondary to another cause (ulcer base, excoriation, necrotic tissue)
  2. Small + large vessel vasculitis
  3. PPD
    - should be PURE lymphocytic
    - superficial perivascular and lichenoids
    - ++ extrav RBC with no vsaculitis
    - hemosiderin pigment +- melanin pigmenet
  4. Neutrophilic dermatoses
    - more neutrophils vs. Vascular damage
66
Q

Name 3 categories of folliculitis

A

Infectious-bacterial. Fungal, viral
Eosinophilic
Acneiform (follicular epithelium attenuated, follicle dilated with keratin plugging it

67
Q

What do you see on path in folliculitis?

A

“Uneven” vasculitis with splaying of neutrophils and nuclear dust in dermis
Infiltrate of neutrophils, later lymph +macrophages

68
Q

On path, how to distinguish scarring vs. Non scarring alopecia

A

Non scarring=normal quantity of follicles present

Scarring= follicles destroyed and replaced with collagen

69
Q

What is dyskeratosis

A

Abnormal keratinization typically indicating cell death

Denseley eosinophilic cytoplasm with pyknotic hyperchromatic nucleas

70
Q

DDx acantholytic dyskeratosis

A

Darier
Warty dyskeratoma
Acanthoma (groin?)
AK, SCC

71
Q

DDX acantholysis w/out dyskeratosis

A

Pemphigus and variants including paraneoplastic
Grovers (PV like, PF like, spongiotic, HH like, Darier like, over acrosynrgia)
Hailey-Hailey
Gali-Gali

72
Q

What is the cornoid lamella

A

Seen in parakeratosis
Clinically correlated to thin thread like border around lesions
Thin, obliquley at 45 degree orientation, column of parakeratosis with diminshed granular layer

73
Q

Name a stain for calcium

A

Von Kossa

74
Q

Name the stain for Fibrin

A

MSB

75
Q

Name the stain for elastin? Collagen?

A

Elastin=elastin

collagen=Trichrome

76
Q

Stain for hemosiderin?

A

PPB

77
Q

What is polarized light on microscopy useful for?

A

Foreign bodies (granuloma, panniculitis, tatoos)

Crystals (gout)

Dense scarred collagen

Bone

Hair shaft abnormalities

78
Q

When is it good to use a GMS stain for fungi?

A

Lots of PMNs, on PAS-diastase can look very dark purple

79
Q

Color of fungi on PAS-D? GMS?

A

PAS- purple

GMS-black on green background

80
Q

What do dermatophytes look like on path?

A

Hyphae with septae, branching

Mold

81
Q

Candida on path?

A

Spores (yeasts) with psuedohyphae (sausage links)

82
Q

Malassezia on path

A

Small yeasts and hyphae= spaghetti and meatballs

83
Q

Syphillis stain?

A

Warthin starry

*TPAL IHC is better

84
Q

3 indications for DIF

A

AI vesiculobullous
Vasculitis
CTD (e.g. lupus)

85
Q

What are 8 things on DDX for invisible dermatoses?

A
  1. Urticaria
  2. Hyperpigmentation d/o -melasma, ephelid, lentigo, cALM
  3. Hypopigmentation-vitiligo, peibaldism, nevus depigemntosus
  4. Urticaria pigementosa/TMEP
  5. MAcular amyloidosis
  6. Tinea
  7. Porokeratosis
  8. Ithcytosis
  9. Argyria
  10. Dermal mucinosis
  11. Anetoderma
  12. Atrophoderma

Others

MyDermatology-Bolognia (31 decks)

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