| Introduction: |
| This patient is a 36 year old female who presented on September 7, 2001 with the chief complaint of a nodule on her left jaw line. The nodule had developed over the period of one month. It was initially pruritic, but eventually became asymptomatic. |
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| History: |
| The patient's past medical history is significant for hypothyroidism and clinical depression. Her medications include Levothroid, Wellbutrin, and Celexa. She has no drug allergies. Her initial laboratory findings were significant only for mild iron deficiency anemia. |
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| Clinical
Presentation: |
| At the initial clinic visit on September 7, 2001, the patient appeared to be a well-nourished, well-developed Caucasian female in no apparent distress. She was alert and oriented x 3, and was in a pleasant and cooperative mood. Skin examination revealed, on the left jaw line, a dome-shaped erythematous nodule measuring 1.2 cm in diameter with a firm consistency, but with mobility in relation to the deeper planes.
At the initial clinic visit, the diagnosis of a granulomatous insect bite reaction was highest on the differential list. Therefore, Cutivate ointment was prescribed to be used for two weeks. However, the patient had no significant improvement, and she returned on September 21, 2001 for a diagnostic punch biopsy. |
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| Pathology: |
| A 4-mm punch biopsy was taken from the nodule. The oficial report read:
"Histologic sections of skin show a dense sheet-like infiltration of atypical mononuclesar cells filling the dermis. The infiltrate spares the papillary dermis and overlying epidermis. The infiltrate is comprised of many small and medium sized mononuclear cels with irregular margins, hyperchromatic nuclei, and prominient nucleoli. A component of small benign-apppearing lymphocytes is also present admixed within this infiltrate as well as a rare eosinophil and plasmacytoid cells. Occasional multinucleated giant cells are seen focally as well as an area of necrosis."
Immunohistochemical stains were also done. They revealed that the infiltrate was composed of CD20+ large atypical mononuclear cells with an admixture of CD3+ small lmphocytes. Kappa immunostain highlighted a rare cell while Lambda immunostain highlighted a larger proportion of cells, indicating a clonal process. |
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| Question
1: |
| What is the differential diagnosis? |
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| Question
2: |
| What other studies will this patient need? |
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| Question
3: |
| What is the appropriate treatment for this patient? |
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