S8C19P6-Erythema Elevatum Diutium


S8C19P6-1: Erythema elevatum diutium.

S8C19P6-2: The vascular changes in this lesion of erythema elevatum diutium are unquestionably those of a vasculitis; they qualify as a necrotizing vascultitis of small dermal vessels. The vessels are outlined by thick sheaths of fibrinoid. As is often the case, even in necrotizing vasculitides, the endothelium is not involved in the necrotizing process. Neutrophils and histiocytes are present in the perivascular infiltrates; there is leukocytoclasia. The fibrinoid changes are widespread along the vascular plexus. As is often the case in cutaneous vasculitides, the epidermis is only minimally affected. A small vessel pattern of this type also could be seen in a cutaneous lesion of polyarteritis nodosa. Only if muscular vessels in the subcutaneous tissue also were found to be involved would the patterns strongly favor polyarteritis nodosa.

S8C19P6-3: In the center of the field, a vessel shows fibrinoid necrosis. There are fragments of nuclear debris in the fibrinoid. The adventitia beyond the zone of necrosis shows lamellar fibrosis with infiltrates of lymphocytes, histiocytes, and neutrophils. A vessel to the left near the bottom of the field shows concentric, hyaline lamellae but, in this anatomic site, the lamellae may represent duplication of basement membrane material; the lumen of this vessel is narrowed (EED).

S8C19P6-4: Even those dermatopathologists, who seem to live to contest, would have difficulty characterizing the patterns as something other than vasculitis. This is a florid, necrotizing, leukocytoclastic angiitis. The florid, fibrinoid necrosis and the extensiveness of the changes along the vascular plexus are features in keeping with an early (young) lesion of erythema elevatum diutium (EED) . Actually, the infiltrates are as rich in migratory histiocytes as neutrophils.

S8C19P6-5: In this example of EED, the acute, fibrinoid changes are not as prominent; there is angioplasia with an increased number of inflamed vessel per unit area. Vessels have thickened walls and swollen endothelium.

S8C19P6-6: These thick-walled vessels have swollen endothelium and narrowed lumens; the vessels have the qualities of post-capillary venules (high endothelium). Near the interface between the papillary dermis and the reticular dermis, there are collections of extravasated red blood cells. The perivascular infiltrates are composed of lymphocytes, histiocytes, and neutrophils. Thin, rigid, fibrous lamellae are a distinctive feature of the connective tissue among the inflamed vessels.

S8C19P6-7: Green arrows outline an area in which parallel, fibrous lamellae are a prominent feature. This type of fibrous reaction is a feature of old lesions of EED.

S8C19P6-8: In this field, the patterns are those of a leukocytoclastic angiitis with fibrinoid in both the wall and the adventitia of the affected vessel. Endothelial cells are preserved and swollen. The brightly eosinophilic, fibrous lamellae (“toxic” hyalin) are a prominent feature in the right, lower corner of the field. In the area of fibrinoid necrosis, neutrophils and histiocytes are loosely spaced; they are also the reacting cells among the brightly acidophilic, fibrous lamellae of the adjacent dermis.

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