@schowardjd

Law | Medicine | @UF #GoGators, @GWAlumni, inter alia | 𝕏 ≠ legal/medical advice | Scientia quaesitor

 United States
Joined January 2009
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Dx: Multifocal cutaneous & musculoskeletal tuberculosis (TB) presenting as tuberculous tenosynovitis, chronic osteomyelitis, & a draining wrist abscess. A Hispanic man in his late 40s developed progressive left wrist swelling, pain, weakness, sensory loss, & restricted mobility over >1 year, followed by a violaceous, fluctuant abscess that spontaneously ruptured. Exam revealed a draining ulcer, palpable subcutaneous nodules & a cord-like lesion extending proximally, forearm/hand atrophy, & median nerve sensory loss. Imaging demonstrated extensive soft-tissue and osseous involvement w/ tenosynovitis. Initial stains & cultures were -ve, but QuantiFERON-TB Gold was +ve; targeted PCR for Mycobacterium tuberculosis complex (IS6110/IS1001) confirmed the diagnosis. The cutaneous findings were most consistent w/ scrofuloderma from contiguous spread of underlying osteoarticular TB. Cutaneous symptoms improved after 3 months of rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE); however, extensive carpal destruction resulted in persistent functional impairment. This case shows the importance of considering extrapulmonary TB in chronic, treatment-refractory abscesses w/ tenosynovitis & osteomyelitis, even w/ -ve AFB stains & cultures and no evidence of pulmonary disease.
Clinical presentation at three-month follow-up. Healing volar wrist abscess after three months on RIPE therapy. Minimal fibrinous exudate present, but no drainage or purulence.

ALT Clinical presentation at three-month follow-up. Healing volar wrist abscess after three months on RIPE therapy. Minimal fibrinous exudate present, but no drainage or purulence.

Scott C. Howard
@schowardjdOct 14
A Hispanic man in his late 40s w/ no significant PMHx presented w/ a chronic L volar wrist abscess following >1 yr of progressive swelling, pain, weakness, sensory loss, & restricted mobility. The lesion enlarged despite prednisone, becoming violaceous & fluctuant before spontaneous rupture. Exam showed an ulcerated, draining abscess, a palpable cord at the L elbow, a subcutaneous nodule on the L upper arm, & forearm/hand atrophy w/ median nerve sensory loss. Imaging demonstrated soft tissue & osseous involvement w/ tenosynovitis. What’s your DDx❓
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A woman in her 60s w/ stage IB RML adenocarcinoma (EGFR exon 21 L858R), s/p lobectomy & mediastinal LN resection in 2021, began adjuvant Tagrisso®️ (osimertinib) 80 mg daily. After ~7 mos of therapy, she developed intense leg pruritus, followed by persistent hyperpigmented, xerotic patches on the B/L arms, thighs, trunk, & back, w/ excoriations on the shins. What’s the diagnosis❔
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xitter.cf/schowardjd/status/2112…
Scott C. Howard
@schowardjd16h
Dx: Erythema dyschromicum perstans (EDP)-like hyperpigmentation induced by osimertinib (Tagrisso®️). A woman in her 60s developed intense pruritus after 7 months of adjuvant osimertinib, followed by persistent, widespread hyperpigmented, xerotic patches involving the trunk & extremities, w/ excoriations on the shins. Bx showed subtle interface dermatitis w/ prominent melanoderma, supporting EDP-like hyperpigmentation. The eruption persisted despite topical triamcinolone 0.1% & tacrolimus 0.1% ointment but gradually lightened approximately 1 year after completing osimertinib therapy. This rare adverse effect of EGFR inhibition should be distinguished from more common drug-associated xerosis, pruritus, & acneiform eruptions, as well as lichen planus pigmentosus.
Biopsy of back with hematoxylin-eosin stain. Mild interface lymphocytic infiltrate, including vacuolar changes of the basal cells and rare dyskeratosis. Dermal telangiectasia with perivascular lymphohistiocytic infiltrate and melanin laden macrophages were also observed (hematoxylin-eosin stain, original magnification x200).

ALT Biopsy of back with hematoxylin-eosin stain. Mild interface lymphocytic infiltrate, including vacuolar changes of the basal cells and rare dyskeratosis. Dermal telangiectasia with perivascular lymphohistiocytic infiltrate and melanin laden macrophages were also observed (hematoxylin-eosin stain, original magnification x200).

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Dx: Erythema dyschromicum perstans (EDP)-like hyperpigmentation induced by osimertinib (Tagrisso®️). A woman in her 60s developed intense pruritus after 7 months of adjuvant osimertinib, followed by persistent, widespread hyperpigmented, xerotic patches involving the trunk & extremities, w/ excoriations on the shins. Bx showed subtle interface dermatitis w/ prominent melanoderma, supporting EDP-like hyperpigmentation. The eruption persisted despite topical triamcinolone 0.1% & tacrolimus 0.1% ointment but gradually lightened approximately 1 year after completing osimertinib therapy. This rare adverse effect of EGFR inhibition should be distinguished from more common drug-associated xerosis, pruritus, & acneiform eruptions, as well as lichen planus pigmentosus.
Biopsy of back with hematoxylin-eosin stain. Mild interface lymphocytic infiltrate, including vacuolar changes of the basal cells and rare dyskeratosis. Dermal telangiectasia with perivascular lymphohistiocytic infiltrate and melanin laden macrophages were also observed (hematoxylin-eosin stain, original magnification x200).

ALT Biopsy of back with hematoxylin-eosin stain. Mild interface lymphocytic infiltrate, including vacuolar changes of the basal cells and rare dyskeratosis. Dermal telangiectasia with perivascular lymphohistiocytic infiltrate and melanin laden macrophages were also observed (hematoxylin-eosin stain, original magnification x200).

Scott C. Howard
@schowardjdOct 14
A woman in her 60s w/ stage IB RML adenocarcinoma (EGFR exon 21 L858R), s/p lobectomy & mediastinal LN resection in 2021, began adjuvant Tagrisso®️ (osimertinib) 80 mg daily. After ~7 mos of therapy, she developed intense leg pruritus, followed by persistent hyperpigmented, xerotic patches on the B/L arms, thighs, trunk, & back, w/ excoriations on the shins. What’s the diagnosis❔
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A woman in her 60s w/ extensive-stage SCLC developed a 4-mo hx of pruritic photosensitive erythema & periorbital edema after starting carboplatin/etoposide/atezolizumab. Symptoms persisted despite systemic corticosteroids & atezolizumab discontinuation. O/E: violaceous periorbital discoloration, photodistributed erythema involving the nasolabial folds, and erythematous-violaceous papules over extensor joints. Skin Bx showed interface dermatitis w/ dermal mucin & eosinophils. Labs: ANA 1:160 speckled, anti-TIF1-γ+, anti-PM/Scl-100+; CK, complements, dsDNA, & antihistone Ab were normal/negative. What’s the diagnosis❔
Cutaneous findings at initial dermatology review.

ALT Cutaneous findings at initial dermatology review.

Histopathology of the skin biopsy, showing interface reaction with dermal mucin deposition (stained with colloidal iron), a superficial lymphocytic infiltrate, and the presence of eosinophils.

ALT Histopathology of the skin biopsy, showing interface reaction with dermal mucin deposition (stained with colloidal iron), a superficial lymphocytic infiltrate, and the presence of eosinophils.

Histopathology of the skin biopsy, showing interface reaction with dermal mucin deposition (stained with colloidal iron), a superficial lymphocytic infiltrate, and the presence of eosinophils.

ALT Histopathology of the skin biopsy, showing interface reaction with dermal mucin deposition (stained with colloidal iron), a superficial lymphocytic infiltrate, and the presence of eosinophils.

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Dx: Purely cutaneous Rosai-Dorfman disease (CRDD). CRDD is a rare form of non-Langerhans cell histiocytosis characterized by accumulation of histiocytes in the skin without lymph node or other extracutaneous involvement. Biopsies showed a dense dermal histiocytic infiltrate with emperipolesis; histiocytes were S100+/CD68+/CD1a−. CT showed no extracutaneous involvement. The lesions spontaneously resolved within 8 weeks without treatment, with no recurrence at 10-month follow-up. Given the variable clinical presentation, Bx & IHC are essential to dx; observation may be appropriate for selected patients w/ skin-limited disease.
Histological features of CRDD. A. Hematoxylin and eosin staining at ×20 magnification showing a dense dermal infiltrate predominantly composed of large histiocytes with abundant cytoplasm, admixed with occasional plasma cells, eosinophils, and neutrophils. B. Higher-power view (×40) highlighting emperipolesis, with the arrow indicating a clear example of an intact inflammatory cell within the cytoplasm of a histiocyte.

ALT Histological features of CRDD. A. Hematoxylin and eosin staining at ×20 magnification showing a dense dermal infiltrate predominantly composed of large histiocytes with abundant cytoplasm, admixed with occasional plasma cells, eosinophils, and neutrophils. B. Higher-power view (×40) highlighting emperipolesis, with the arrow indicating a clear example of an intact inflammatory cell within the cytoplasm of a histiocyte.

Immunohistochemical features of cutaneous Rosai–Dorfman disease. (A) Histiocytes showing strong positivity for CD68. (B) Diffuse S100 immunoreactivity.

ALT Immunohistochemical features of cutaneous Rosai–Dorfman disease. (A) Histiocytes showing strong positivity for CD68. (B) Diffuse S100 immunoreactivity.

Immunohistochemical features of cutaneous Rosai–Dorfman disease. (C) Absence of CD1a expression. The immunophenotypic profile (CD68⁺, S100⁺, CD1a⁻) is compatible with Rosai–Dorfman disease.

ALT Immunohistochemical features of cutaneous Rosai–Dorfman disease. (C) Absence of CD1a expression. The immunophenotypic profile (CD68⁺, S100⁺, CD1a⁻) is compatible with Rosai–Dorfman disease.

Scott C. Howard
@schowardjdOct 13
A man in his 70s w/ no significant PMHx presented w/ a 1-mo hx of rapidly increasing, tender erythematous-yellow papules & nodules (4 mm–2 cm) on the trunk & UEs. Lesions were polymorphic, ranging from dome-shaped, infiltrated nodules to keratotic or superficially eroded papules. No LAD, constitutional sx, or identifiable triggers. CBC was unremarkable; SPEP showed no polyclonal hypergammaglobulinemia, & HBV, HCV, HIV, & syphilis serologies were -ve. What’s the diagnosis❓
Tumor-like, hyperkeratotic nodule on the right pectoral region.

ALT Tumor-like, hyperkeratotic nodule on the right pectoral region.

A tumor-like lesion in the left thoracic paravertebral region and an additional lesion over the left lateral scapular area.

ALT A tumor-like lesion in the left thoracic paravertebral region and an additional lesion over the left lateral scapular area.

Dermoscopy of lesion at 30x magnification. Pinkish papule overlayed by a central ulceration, surrounded by fine linear vessels.

ALT Dermoscopy of lesion at 30x magnification. Pinkish papule overlayed by a central ulceration, surrounded by fine linear vessels.

Dermoscopy of lesion at 30x magnification. Papule with a central orangish-yellowish area and a peripheral crust.

ALT Dermoscopy of lesion at 30x magnification. Papule with a central orangish-yellowish area and a peripheral crust.

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Purely cutaneous Rosai–Dorfman disease (cutaneous RDD; cutaneous sinus histiocytosis w/ massive lymphadenopathy), presenting as multifocal eruptive papulonodules. The rapid appearance of polymorphic red-yellow papules & tumor-like nodules, some keratotic or ulcerated, in an older patient w/o LAD or systemic symptoms is characteristic of cutaneous RDD w/o nodal disease. The orange-yellow dermoscopic areas reflect the histiocytic infiltrate. Absence of polyclonal hypergammaglobulinemia does not exclude isolated cutaneous RDD. <@GeminiApp 3.8 Flash via @MedicalSphereAI>
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A man in his 80s w/ HTN, T2DM, and GERD presented w/ a 2-y hx of progressively increasing, mildly pruritic keratotic lesions on both palms. O/E: numerous, diffusely distributed, firmly adherent 1–2 mm hyperkeratotic papules confined to the palmar surfaces. Punch Bx showed orthokeratotic hyperkeratosis w/ focal columns of parakeratosis overlying a diminished granular layer. What’s the diagnosis❔
Multiple punctate keratotic projections involving the thumb.

ALT Multiple punctate keratotic projections involving the thumb.

Diffuse punctate hyperkeratotic papules involving the palm with the selected punch biopsy site marked.

ALT Diffuse punctate hyperkeratotic papules involving the palm with the selected punch biopsy site marked.

Diffuse distribution of scattered hyperkeratotic papules across the palmar surface.

ALT Diffuse distribution of scattered hyperkeratotic papules across the palmar surface.

Histopathologic examination demonstrating a column of parakeratotic hyperkeratosis arising from a depression in the epidermis with underlying hypogranulosis.

ALT Histopathologic examination demonstrating a column of parakeratotic hyperkeratosis arising from a depression in the epidermis with underlying hypogranulosis.

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A teenage male presented with a 1-year hx of an initially pruritic eruption that began on the trunk & progressively spread across the trunk and B/L extremities, sparing the hands & feet. Lesions were skin-colored to ivory-white sclerotic papules w/ hyperpigmented brown borders & had become asymptomatic. He denied prior similar episodes, recent illness, travel, sick contacts, new meds, or recreational drug use. He had no hx or clinical evidence of Raynaud phenomenon. ANA, anti-SSB, anti-Scl-70, anti-ssDNA, anti-Smith, anti-Ro52/Ro60, & anti-RNP antibodies were unremarkable. What’s the diagnosis❔
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Dx: Generalized morphea w/ active, function-limiting acral inflammation. Bx of the dorsal foot showed dermal sclerosis w/ superficial, mid, & deep lymphoplasmacytic inflammation, whereas the older-appearing abdominal plaques showed sclerosis w/ minimal inflammation. Oral PUVA photochemotherapy (methoxsalen + UVA) improved pain, followed by off-label RINVOQ®️ (upadacitinib) (initially 45 mg daily for 9 days, then 15 mg daily), w/ marked improvement in erythema, induration, pain, & ambulation within 3 weeks. Repeat Bx showed reduced inflammation.
Clinical improvement at 8 weeks after starting upadacitinib, corresponding to the repeat biopsy.

ALT Clinical improvement at 8 weeks after starting upadacitinib, corresponding to the repeat biopsy.

Morphea histopathology of the right dorsal foot. Pretreatment dermal sclerosis with lymphoplasmacytic inflammation.

ALT Morphea histopathology of the right dorsal foot. Pretreatment dermal sclerosis with lymphoplasmacytic inflammation.

Repeat biopsy adjacent to the initial site at 8 weeks after starting upadacitinib, showing a marked qualitative reduction in inflammation. Hematoxylin and eosin, low-power views.

ALT Repeat biopsy adjacent to the initial site at 8 weeks after starting upadacitinib, showing a marked qualitative reduction in inflammation. Hematoxylin and eosin, low-power views.

Scott C. Howard
@schowardjdOct 13
A woman in her 60s presented w/ progressive sclerotic plaques involving the trunk, distal pretibial legs, ankles, & dorsal feet, affecting ~20% BSA. Abdominal plaques had developed several years before the acral lesions. Exam showed firm, ivory-white abdominal plaques & indurated, bound-down plaques of the B/L feet, ankles, & distal legs, w/ prominent violaceous erythema & focal ivory-white areas at the ankles. Acral disease caused pain, tightness, & limited ambulation despite topical calcipotriene. What’s the diagnosis❔
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Generalized morphea (localized scleroderma) w/ active Inflammatory acral disease <@claudeai Opus 5.5 via @MedicalSphereAI>
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Dx: Cutaneous metastases of rectal adenocarcinoma. Progressive genital, perineal, & buttock ulcerations w/ marked edema, drainage, & indurated violaceous nodules failed to improve w/ tx for presumed radiation injury, prompting Bx. Histopath showed an atypical dermal gland-forming neoplasm w/ focal epidermotropism and necrosis; IHC was +ve for CK7, CK20, CDX2, & focally SATB2, supporting colorectal origin. CT subsequently revealed multiple pulmonary nodules suspicious for mets. The patient elected palliative care & died approximately 6 months after dx. This case shows that cutaneous mets can mimic radiation-induced injury & warrant Bx of progressive, tx-refractory lesions in patients w/ a hx of malignancy, even when routine surveillance shows no local recurrence.
Extensive dermal glandular proliferation, mixed inflammation and intraglandular debris, with focal epidermotropism and ulceration (hematoxylin-and-eosin; original magnification 12.5x).

ALT Extensive dermal glandular proliferation, mixed inflammation and intraglandular debris, with focal epidermotropism and ulceration (hematoxylin-and-eosin; original magnification 12.5x).

Extensive dermal glandular proliferation, mixed inflammation and intraglandular debris, with focal epidermotropism and ulceration (hematoxylin-and-eosin; original magnification 50x).

ALT Extensive dermal glandular proliferation, mixed inflammation and intraglandular debris, with focal epidermotropism and ulceration (hematoxylin-and-eosin; original magnification 50x).

Tumor cells were immunoreactive for: (A) Cytokeratin 7 (CK7); (B) Cytokeratin 20 (CK20); (C) Caudal-type Homeobox 2 (CDX2); and (D) Special AT-rich sequence-binding protein 2 (SATB2), focally (original magnification (A, B, C) 12.5x, and (D) 100x), consistent with gastrointestinal primary.

ALT Tumor cells were immunoreactive for: (A) Cytokeratin 7 (CK7); (B) Cytokeratin 20 (CK20); (C) Caudal-type Homeobox 2 (CDX2); and (D) Special AT-rich sequence-binding protein 2 (SATB2), focally (original magnification (A, B, C) 12.5x, and (D) 100x), consistent with gastrointestinal primary.

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Dx: Severe scrotal lichen simplex chronicus (LSC) secondary to chronic pruritus. Bx showed irregular epidermal acanthosis, compact hyperkeratosis, hypergranulosis, vertical collagen streaking, & dermal fibrosis. Pruritus & ulcerations persisted despite topical corticosteroids, gabapentin, & 21 months of dupilumab, including escalation to weekly dosing. Switching to nemolizumab (60 mg loading dose, then 30 mg SC q4wk) resulted in complete pruritus & ulceration resolution after 3 doses, w/ marked improvement in skin thickening sustained through 12 months.
Significant improvement of cutaneous manifestations of scrotal pruritus and severe lichen simplex chronicus after 3 doses of nemolizumab.

ALT Significant improvement of cutaneous manifestations of scrotal pruritus and severe lichen simplex chronicus after 3 doses of nemolizumab.

Histopathologic examination revealed broad irregular epidermal acanthosis with massive overlying compact hyperkeratosis and hypergranulosis.

ALT Histopathologic examination revealed broad irregular epidermal acanthosis with massive overlying compact hyperkeratosis and hypergranulosis.

A jagged ridge pattern was evident with sparse lymphocytes (short arrow), vertical streaking of collagen (long arrow), and diffuse subjacent dermal fibrosis.

ALT A jagged ridge pattern was evident with sparse lymphocytes (short arrow), vertical streaking of collagen (long arrow), and diffuse subjacent dermal fibrosis.

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Severe scrotal LSC 2/2 chronic pruritus.
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Dx: Subungual melanoma in situ with microinvasion (Breslow depth 0.2 mm) and a germline pathogenic CHEK2 variant (c.1100delC). Widening of a longstanding pigmented band of the L fourth fingernail prompted Bx. Subsequent excision revealed microinvasive melanoma w/ a +ve deep margin, requiring distal amputation at the DIP joint. Given her sister’s early-onset breast cancer (age 44) & multiple paternal relatives’ w/ malignancies, genetic testing identified a pathogenic CHEK2 frameshift variant, prompting referral for breast oncology risk assessment, enhanced surveillance, & cascade testing. CHEK2 is associated w/ increased breast cancer risk & may confer a moderate increase in melanoma risk, although melanoma-specific screening recommendations remain uncertain. <@GeminiApp 3.8 Flash via @MedicalSphereAI>
Scott C. Howard
@schowardjdOct 13
A woman in her late 60s w/ a hx of UV gel manicures & prior sunburns, but no tanning bed use, presented w/ widening of a longstanding, thin tan band on the L fourth fingernail. What’s the diagnosis❓
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A woman in her 20s w/ anxiety presented w/ an 8-day hx of a diffuse, pruritic eruption, fever, chills, & facial edema beginning after starting kava tea 2 wks earlier. O/E: widespread pustules on edematous erythematous plaques, w/ prominent periorbital edema & sparing of the palms, soles, & mucosae. Labs revealed neutrophilic leukocytosis & transaminitis (AST 232, ALT 355 U/L). She had been taking stable-dose fluoxetine for 3 mos. What’s the diagnosis❔
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Dx: Cutaneous metastasis of endometrial adenocarcinoma. Bx of the rapidly enlarging, tender scalp nodule showed poorly differentiated carcinoma w/ AE1/AE3, CK7, ER, & PAX8 positivity & focal PR positivity, supporting endometrial origin. Given refractory metastatic disease, Mohs micrographic surgery was performed for palliation, achieving clearance in 2 stages w/ uneventful healing and no local recurrence.
Postoperative image demonstrating a well-healed surgical site without evidence of residual tumor.

ALT Postoperative image demonstrating a well-healed surgical site without evidence of residual tumor.

Formalin fixed, paraffin embedded debulked specimen stained with H&E demonstrates multiple nodules of poorly differentiated epithelial cells with increased mitotic activity associated with dense necrosis and reactive inflammation.

ALT Formalin fixed, paraffin embedded debulked specimen stained with H&E demonstrates multiple nodules of poorly differentiated epithelial cells with increased mitotic activity associated with dense necrosis and reactive inflammation.

Scott C. Howard
@schowardjdOct 13
A woman in her 70s w/ recurrent endometrial carcinoma presented w/ a rapidly enlarging, tender, well-circumscribed scalp nodule of one-week’s duration. What’s the diagnosis❓
Gross image of the tumor located on the left parietal scalp.

ALT Gross image of the tumor located on the left parietal scalp.

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Cutaneous metastasis of recurrent endometrial carcinoma to the scalp (potentially a rapidly growing, friable/vascular-appearing metastatic nodule). <@claudeai Opus 5.5 via @MedicalSphereAI>
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A woman in her 40s presented for evaluation of lesion on her left nasal bridge. Dermoscopy revealed a 0.6 cm pearly papule with beads of pigmentation & arborizing vessels. What’s the diagnosis❓
Dermatoscopic imaging demonstrates crisp, arborizing blood vessels, with some blue-grey blotches and pigment without a network.

ALT Dermatoscopic imaging demonstrates crisp, arborizing blood vessels, with some blue-grey blotches and pigment without a network.

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A Hispanic man in his late 40s w/ no significant PMHx presented w/ a chronic L volar wrist abscess following >1 yr of progressive swelling, pain, weakness, sensory loss, & restricted mobility. The lesion enlarged despite prednisone, becoming violaceous & fluctuant before spontaneous rupture. Exam showed an ulcerated, draining abscess, a palpable cord at the L elbow, a subcutaneous nodule on the L upper arm, & forearm/hand atrophy w/ median nerve sensory loss. Imaging demonstrated soft tissue & osseous involvement w/ tenosynovitis. What’s your DDx❓
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