Retroauricular ulcer in a patient with a history of multiple skin cancers

Presenter: Tony Nakhla, D.O.
Dermatology Program: Western University/Pacific Hospital of Long Beach
Program Director: David C. Horowitz, D.O.
Submitted on: Sep 17, 2008

CHIEF COMPLAINT:  “I have a skin cancer behind my ear”

CLINICAL HISTORY:

Signs and symptoms:  A 55 year old white male who presented to our clinic with a 2 week history of a painful sore on the right post auricular region.

Previous Treatment:  None

Other information:  The patient has a past medical history of multiple non-melanoma skin cancers including five squamous cell carcinoma and six basal cell carcinomas, three of which required Mohs. He reports no other significant past medical history and is on no medications. He smokes approximately one pack per day. The patient has no medical insurance and was concerned with procedural costs. He was willing to pay for a complete excision but did not want to pay for a biopsy, since due to his history, he was convinced it was another skin cancer which needed to be removed

PHYSICAL EXAM:

Cachectic 55 year old white male with poor hygiene. Large (approx 4.3x 3.5 cm), tender, ulcerated, erythematous plaque with impetiginized crusts and purulent drainage was present around and within the right retro-auricular sulcus.

 

Retroauricular ulcer with impetiginized crust

LABORATORY TESTS:

None

DERMATOHISTOPATHOLOGY:

Microscopic examination revealed a dome shaped, granulomatous infiltrate of foreign body giant cells, lymphocytes, and macrophages.

 

Dome shaped, granulomatous infiltrate

 

 

Foreign body giant cells composed of lymphocytes, neutrophils, eosinophils and macrophages present in the dermis.

 

Numerous encapsulated, round to ovoid spores were present within macrophages and giant cells as well as in free spaces.

 

Numerous encapsulated, round to ovoid spores were present within macrophages and giant cells as well as in free spaces.

 

A PAS stain was performed which highlighted the spores.

 

PAS stain

 

A mucicarmine stain was positive confirming the diagnosis of cutaneous cryptococcosis

 

Mucicarmine stain

 

DIFFERENTIAL DIAGNOSIS:

1.   Squamous Cell Carcinoma
2.   Basal Cell Carcinoma
3.   Infectious
4.   Factitial/Traumatic


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