CLINICAL PATHOLOGIC CHALLENGE

Targetoid Eruptions: Challenge M. Drake Poeschl, MD,* M. Yadira Hurley, MD,* Sagun D. Goyal, MD,† and Claudia I. Vidal, MD*

(Am J Dermatopathol 2014;36:827–828)

CLINICAL PRESENTATION A 28-year old white man presented with a 10-day history of a disseminated rash. The patient had recently been diagnosed with Burkitt lymphoma and had begun taking trimethoprim-sulfamethoxazole prophylactically as a part of his chemotherapy regimen. He initially noticed the rash over the left side of his trunk, which then progressed over a period of days to involve the remainder of his trunk, extremities, and scalp. Physical examination revealed red edematous papules and plaques involving the head, trunk, and extremities (Fig. 1). Older areas were beginning to resolve with peripheral desquamation. Many of the smaller plaques and papules had a dusky brown center with a red rim resembling atypical target lesions (Fig. 2). There was no mucosal or palmoplantar involvement.

HISTOPATHOLOGICAL FINDINGS

Punch biopsies from the right flank and right forearm demonstrated neutrophilic spongiosis with nonfollicularbased subcorneal pustules (Figs. 3, 4). In the dermis, there was a perivascular and interstitial mixed infiltrate of lymphocytes and neutrophils, vascular ectasia, and dermal edema. Fungal stains were negative (Table 1).

WHAT IS YOUR DIAGNOSIS? (Continued on page 838)

FIGURE 1. Edematous coalescing red papules and plaques on the trunk and upper extremities. From the Departments of *Dermatology and †Internal Medicine, Saint Louis University, St Louis, MO. The authors declare no conflicts of interest. Reprints: M. Drake Poeschl, MD, Saint Louis University, Department of Dermatology, Anheuser Busch Institute, 1755 South Grand Blvd. St. Louis, MO 63104 (e-mail: [email protected]). © 2014 Lippincott Williams & Wilkins

Am J Dermatopathol  Volume 36, Number 10, October 2014

FIGURE 2. Atypical target lesions with dusky brown centers and erythematous rim. www.amjdermatopathology.com |

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TABLE 1. Comparison of Clinical and Histopathological Features Between Acute Generalized Exanthematous Pustulosis (AGEP), Urticaria Multiforme, and Erythema Multiforme Urticaria Multiforme

AGEP

FIGURE 3. Punch biopsy from the right forearm showing spongiosis with a subcorneal pustule and a sparse perivascular dermal infiltrate (H&E ·100).

Demographics

Usually adults

Location

Intertriginous areas and face Days to weeks

Duration of lesions Facial or acral Rare edema Dermatographism Rare Etiology Drugs, most commonly antibiotics Histopathology Nonfollicular subcorneal and/ or intraepidermal pustules

Erythema Multiforme

Infants and Children and children adults Trunk, extremities, Hands, feet, face genitalia Less than 24 hours Days to weeks Common

Rare

Common Rare Antibiotics, Herpes simplex infections, virus, other viral immunizations illnesses Dermal edema Vacuolar interface with a sparse dermatitis with perivascular varying degrees infiltrate of epidermal including necrosis neutrophils and eosinophils

FIGURE 4. Subcorneal pustule (H&E ·400).

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 2014 Lippincott Williams & Wilkins