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 Table of Contents  
LETTER TO EDITOR
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 46-48

Coincidence of two minor tissue reaction patterns: Eosinophilic flame figures and transepidermal elimination in histopathology of arthropod bite reaction


1 Department of Dermatology, Tehran University of Medical Sciences, Tehran, Iran
2 Dermatopathology, Razi Hospital, Tehran University of Medical Sciences; Department of Pathology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran

Date of Submission05-Oct-2018
Date of Decision25-Jan-2019
Date of Acceptance14-Jul-2019
Date of Web Publication02-Jun-2020

Correspondence Address:
Alireza Ghanadan
Dermatopathology, Razi Hospital, Tehran University of Medical Sciences; Department of Pathology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdpdd.ijdpdd_62_18

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How to cite this article:
Moghadas S, Bafruee NB, Nasimi M, Ghanadan A. Coincidence of two minor tissue reaction patterns: Eosinophilic flame figures and transepidermal elimination in histopathology of arthropod bite reaction. Indian J Dermatopathol Diagn Dermatol 2020;7:46-8

How to cite this URL:
Moghadas S, Bafruee NB, Nasimi M, Ghanadan A. Coincidence of two minor tissue reaction patterns: Eosinophilic flame figures and transepidermal elimination in histopathology of arthropod bite reaction. Indian J Dermatopathol Diagn Dermatol [serial online] 2020 [cited 2020 Aug 11];7:46-8. Available from: http://www.ijdpdd.com/text.asp?2020/7/1/46/285808



Sir,

Insect bites on human skin are fairly common occurrences. Various cutaneous lesions including maculae, urticaria, papules, vesicles, pustules, bullae, nodules, erosions, and excoriations observed in response to insect bites are not specific for a particular arthropod, and these reactions vary individually, so to distinct bites from other cutaneous diseases, a histologic examination can be helpful.[1]

Histopathologic features include dermal edema with superficial and deep perivascular and wedge-shaped inflammation. The infiltrate can be deep, and subcutaneous fat may be affected. Its components may vary, including lymphocytes, histiocytes, neutrophils, and eosinophils. Prominent interstitial eosinophils between collagen bundles can be of diagnostic value.[2]

A 12-year-old boy with no medical history presented to our dermatology clinic with pruritic lesions for 2 weeks. Physical examination revealed numerous papules and plaques with central crust and erythematous borders on the trunk and extremities. Some of the lesions had a linear distribution. The patient had no systemic symptoms, and the physical examination was otherwise normal. Clinical impressions include insect bite reaction, papular urticaria, neurotic excoriation, and perforating disorder [Figure 1].
Figure 1: Papules and plaques with central crust and linear distribution on the trunk

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A punch biopsy was taken from one of the papules to rule out other clinical differential diagnosis. The histopathologic features include superficial and deep perivascular and interstitial infiltrate of mixed inflammatory cells composed of numerous eosinophils, some lymphocytes, and histiocytes with subcutaneous fat involvement. Eosinophilic flame figures and transepidermal elimination (TE) of degenerated material through epidermis with vacuum cleaner appearance was also observed [Figure 2].
Figure 2: Superficial and deep perivascular infiltration of lymphocytes and histiocytes admixed with many eosinophils (a: H and E, ×10), numerous eosinophils around thickened blood vessels (b: H and E, ×40), collagen degeneration with flame figure and eosinophils (c: H and E, ×40), transepidermal elimination of altered dermal collagen with flame figure (d: H and E, ×10), vacuum cleaner feature of epidermis extruding degenerated materials through epidermis (e: H and E, ×20)

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We represent an interesting pathology image showing coincidence of two minor tissue reaction patterns, including flame figures and TE. Flame figures, developed by deposition of major basic protein of eosinophils around collagen fibers in dermis are hallmark of wells' syndrome, but they are not specific and may be seen in other disorders such as arthropod bites and stings, mastocytoma, parasitic infection, prurigo nodularis, eczema, and dermatophyte infection.[3]

TE is a mechanism that causes foreign or altered material to be removed from the dermis. In this regard, the epidermis or follicular epithelium becomes hyperplastic and form elongated tongues that engulf irritating material. Thereafter, the entrapped material gradually moves toward epidermis because of the underlying newly forming epidermis. Finally, dermal components extrude to the skin surface.[4]

TE is seen in two categories of disorders:

  1. Primary dermatoses (reactive perforating collagenosis, elastosis perforans serpiginosa)
  2. Secondary forms that known as acquired perforating dermatosis (APD).[5]


APD develop during adulthood and usually in conjunction with diabetes mellitus and chronic renal failure, but can also arise in association with other causes of pruritus, such as insect bites, scabies, lymphoma, and hepatobiliary diseases. APD may also occur in trauma sites (e.g., healing herpes zoster) or after drug exposure (e.g., tumor necrosis factor-alpha inhibitors, bevacizumab, sirolimus, and indinavir), and even in otherwise healthy patients.

The etiopathogenesis of APD is not fully understood, but several hypotheses have been proposed, such as epidermal and connective tissue damage due to scratching. Another theory says that diabetic vasculopathy may predispose to APD in diabetic patients who scratch their skin. One more hypothesis focuses on the metabolic disturbances or microdeposition of substances such as calcium salts that cause alteration in collagen or elastic fibers.

To the best of our knowledge, this is the first report that represents two minor tissue reaction patterns of flame figures and TE simultaneously in one case with the etiology of bite assault.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Miteva M, Elsner P, Ziemer M. A histopathologic study of arthropod bite reactions in 20 patients highlights relevant adnexal involvement. J Cutan Pathol 2009;36:26-33.  Back to cited text no. 1
    
2.
Battistella M, Bourrat E, Fardet L, Saada V, Janin A, Vignon-Pennamen MD. Sweet-like reaction due to arthropod bites: A histopathologic pitfall. Am J Dermatopathol 2012;34:442-5.  Back to cited text no. 2
    
3.
Stenson CL, Leiferman KM. Eosinophilic dermatoses. In: Bolognia J, Jorizzo JL, Schaffer JV, editors. Dermatology. Philadelphia: Elsevier Saunders; 2012. p. 1711-28.  Back to cited text no. 3
    
4.
Hong SB, Park JH, Ihm CG, Kim NI. Acquired perforating dermatosis in patients with chronic renal failure and diabetes mellitus. J Korean Med Sci 2004;19:283-8.  Back to cited text no. 4
    
5.
Woo TY, Rasmussen JE. Disorders of transepidermal elimination. Part 2. Int J Dermatol 1985;24:337-48.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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