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Napa Valley Dermatopathology Meeting 2018 -

Select Infections & Infestations

Whitney A. High, MD, JD, MEngwhitney.high@ucdenver.edu

Professor of Dermatology & Pathology

Vice-Chairman, Dermatology

Director of Dermatopathology

Director of Adult Dermatology Clinic

University of Colorado School of Medicine

May 17, 2018

Napa, CA

Viral Infections

Chicken Pox

• Varicella zoster virus

• Clinical

– often children

– crops of lesions

– centripetal accentuation

“R/O folliculitis vs. PLEVA”

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Epidermal

Necrosis

Vesiculation

Multinucleated

Keratinocytes

Acantholysis with

“Cytopathic Effect”

Eosinophilic

Intranuclear Inclusions

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Zoster

VZV IHC

Case

• 24 year old EKG tech

• Seen at PCP for “odd rash”

• 72 hour h/o scattered lesions on all body

• Had vaccinations for VZV

– 1994 and 2009

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Tip:VZV (and sometimes HSV) may

be very folliculocentric in nature

Tip: viral infections can be confused with lymphomas

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Unusual Case

• 46 y/o HIV(+) male

• Painful genital ulcer

• Enlarging x 12 months

• Failed 6 courses of ACV

• Off HAART x 2 months

• Two prior HSV cultures by ID were negative

Initial Histological Assessment• Assessed in Pathology Department

“Bug” stains – negative

CD3

CD20

CD79

BCl-2

Kappa

Lambda

• No specific diagnosis rendered.

• “Worrisome for plasmacytoid

lymphoma. Will consult with ****.”

• **** also believed it was “worrisome

for lymphoma, but not diagnostic.”

Histology

10x

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Histology

20x

40x

CD20 Stain

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HSV Stain

PCR (+) HSV II

Cx (+) ACV resistant strain

20x10x 40x

Diagnosis: Acyclovir resistant HSV II infection

Bacterial Infections

76 year-old man

Fremont County, Colorado

“rash x years”

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FiteAFB

This is all the

same infection

This is still all the same infection…

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Syphilis!

Tip: There is one disease that can be

included in almost any inflammatory

differential diagnosis -

Secondary SyphilisSuperficial & Deep with Plasma Cells

Copious

Plasma

Cells

This is syphilis…

Lichenoid and slightly psoriasiform

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This is syphilis also…

• 19 cases of secondary syphilis

– superficial and deep perivascular pattern (9)

– lichenoid pattern (4)

– combined pattern (6)

• Plasma cells were sparse in 4 cases

• Granulomas in 53% of cases

• Papillary edema and plump endothelial cells common

• Perineural infiltrate was seen in 74% of cases

• Variable acanthosis and dyskeratosis in the epidermis

Secondary SyphilisImmunohistochemical Studies

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Tip: If syphilis is a possibility, always

recommended serologic testing.

Fungal Infections

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“R/O

PG”

Tip:

Awareness of PG has increased

remarkably, and that is great, but

it is still a “rule out” diagnosis.

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“R/O PG”

In my clinic.

Certainly has

some unusual

features of PG

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Tip:

KOH Prep

It works!

Second Biopsy…

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Blastomycosis

• Caused by dimorphic fungus - Blastomyces dermatitidis

• Associated with hunting, forestry, excavation, fishing

gardening and trapping

• Lungs, skin, bones often affected

• Acute disease can be fulminant

– 68% of patients presenting with ARDS

• #1 treatment – itraconazole

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Protozoal Infections

Unusual Case• 53 year old CU professor

• “SCC of the ear” → Mohs

• After surgery:

– persistent inflammation,

– warmth

– swelling

• Post surgical chondritis?

Ulcer

Serous, hemorrhagic and

inflammatory crusting

Continued inflammatory

infiltrate in the dermis

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Russell body Mott cell

Mostly lymphocytes, histiocytes, plasma cells

Minute “dots” getting even larger yet, among the

otherwise chronic inflammation

Look here!

Case

29 year old woman

Yoga instructor

Recent travel to

Costa Rica

Recent outside dx

of SCC

Sent to Mohs

surgeon

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CDC Results

(free of charge)

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Tip:

BE CAREFUL - Leishmaniasis

can cause features that mimic

SCC and too few clinicians

provide a history that would

actually increase suspicion.

Nematode Infection

Case

52 year-old man from Lima

Migratory urticarial plaques

Family of money and influence

Eats ceviche ≥ twice/week

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Gnathostomiasis

• Fish nematode - Gnathostoma spinigerum

• “Emerging pathogen”

• Formerly of Thailand, now in Mexico & Peru

• Can cause of eosinophilic meningitis

• Anisakis more common illness from sushi (but requires a inept chef)

What has been will be again, what has been done will

be done again; there is nothing new under the sun.

- Eccl. 1:9

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Tip:

Don’t eat raw fish!

Infestations

ScabiesSarcoptes scabiei var hominis

• Arachnid (8 legs)

• Ubiquitous

• First visualized in 1687 in Italy

• Often occurs in 30 year epidemics

• Last epidemic from 1960’s still continuing

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ScabiesClinical

Wrist area

Penile Nodules

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“Real world” results of a good

scabies prep…

ScabiesCrusted Variant (HIV patient)

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The Scourge

• Cimex lectularius

– bed bug

– bedbug

• A true insect

• 6 legs

• Life cycle requires a blood

meal to molt

5-7

mm

Armed Forces Pest Management Board Image Database (Public Domain)

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The Bites

Superficial and

deep perivascular

dermatitis with

eosinophils.

Thank you.