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354030245X Dermatopathology.Pdf Eva Brehmer-Andersson Dermatopathology Eva Brehmer-Andersson Dermatopathology With 138 Figures in 445 Separate Illustrations and 5 Tables 123 Eva Brehmer-Andersson Värtavägen 17 115 53 Stockholm Sweden ISBN-10 3-540- 30245-X Springer-Verlag Berlin Heidelberg NewYork ISBN-13 978-3-540- 30245-2 Springer-Verlag Berlin Heidelberg NewYork Library of Congress Control Number: 2006920598 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, speci.cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on micro.lms or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law. Springer is a part of Springer Science+Business Media springer.com © Springer-Verlag Berlin Heidelberg 2006 Printed in Germany The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: the publishers cannot guarantee the accuracy of any information about dos- age and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Editor: Gabriele Schröder, Heidelberg Desk Editor: Ellen Blasig, Heidelberg Production and Typesetting: LE-TEX Jelonek, Schmidt & Vöckler GbR, Leipzig Cover Design: Frido Steinen-Broo, EStudio Calamar, Spain Printed on acid-free paper 24/3100/YL 5 4 3 2 1 0 Preface The purpose of this book is to introduce future pathologists and dermatolo- gists to the exciting field of dermatopathology. During the past 40 years der- matopathology has become a big and important topic. There are today many excellent and comprehensive textbooks on the subject, but the overwhelming amount of material and increasing number of this kind of textbook make it difficult to start to discover new fields. I have chosen to focus on relevant pro- cesses in basic pathology and discuss how they work or are supposed to work in both common and unusual skin diseases, which I have been confronted with during a life-long practice in pathology and dermatopathology. I also focus on some controversial concepts prevailing and on the diversity in no- menclature. My expectation is to promote the understanding of pathogenesis in diseases of the skin and arouse an appetite for further and more compre- hensive studies, and hopefully even to inspire new fruitful investigations. In this respect, the book will even address those experienced in the specialty. Eva Brehmer-Andersson March 2006 Acknowledgement This book is based on experiences acquired at the Departments of Pathology of the University Hospitals in Lund and Umeå, and at the Karolinska Univer- sity Hospital and South Hospital in Stockholm, Sweden. In all these places I have had a close and inspiring collaboration with the respective Departments of Dermatology. I want to heartily thank all staff members who during the years, besides their own routine work, have willingly helped me with impor- tant things such as further sections and stainings, and searching for old slides, records and print-outs. I am deeply indebted to Sven Lindskog, Professor at the Department of Oral Histology, Karolinska Institute, Stockholm, for generously having put his photo laboratory at my disposal, and to Karl Gabor, colleague and photogra- pher, for valuable advice about adaptation of the photographic material. Contents 1 Requirements for a Good 4.1.4 Immune Response in Non-Lymphoid Diagnostic Result Tissues . 15 4.1.5 Cytokines and Cell Adhesion Molecules . 15 1.1 Sampling Technique . 1 4.2 Innate Immunity . 16 1.2 The Consulting Form.............. 1 4.2.1 The Complement System........... 17 1.3 Routine Processing . 2 4.2.1.1 The Classic Pathway . 17 1.4 Interpretation of Histopathologic Changes . 2 4.2.1.2 The Alternative Pathway . 17 4.3 Adverse Reactions of the Immune System . 17 4.3.1 Type I. Immediate Reactions . 17 2 The Dermal Blood Vasculature 4.3.2 Type II. Cytotoxic Antibody-Dependent Reactions.................... 17 2.1 General Architecture of Blood Vessels . 4 4.3.3 Type III. Reactions due to Circulating 2.1.1 Arteries...................... 4 Immune Complex Activated by 2.1.2 Capillaries . 4 Complement.................. 18 2.1.3 Veins . 4 4.3.4 Type IV. Cell-Mediated Hypersensitivity 2.1.4 The Endothelium . 5 Reactions.................... 18 2.1.5 Arteriovenous Anastomoses .......... 5 4.4 The Skin Immune System . 18 2.2 The Microvasculature of the Skin . 5 4.4.1 Lymphocytes in Normal Skin . 18 References .......................... 6 4.4.2 Langerhans Cells . 18 4.4.3 Keratinocytes . 19 4.5 The Immune Response and Skin Diseases . 19 3 The Dermal Lymphatic Vasculature References ......................... 19 3.1 The Construction of Lymphatic Capillaries . 9 3.2 Lymphatic Capillaries in the Skin ....... 9 5 Cell and Vascular Response 3.3 Prelymphatics and Initial Lymphatics to Infection and Injury (Lymphatic Sinusoids, Blind Tubes) . 10 References ......................... 11 5.1 Inflammatory Cells . 21 5.1.1 Neutrophils . 21 5.1.2 Eosinophils . 21 4 The Immune Response 5.1.3 Lymphocytes . 21 5.1.4 Plasma Cells.................. 22 4.1 Adaptive Immunity.............. 12 5.1.5 Mast Cells . 22 4.1.1 B and T Cells . 12 5.1.6 Basophils.................... 23 4.1.2 The Lymph Node . 13 5.1.7 Monocytes/Macrophages . 23 4.1.2.1 The Cortex—the Main Territory for B Cells 13 5.2 Acute Inflammation . 23 4.1.2.2 Paracortex or Deep Cortex—the Main 5.2.1 Active Phase.................. 23 Territory for T Cells . 14 5.2.2 Healing Without Residue . 24 4.1.2.3 Medulla—the Area Between the Paracortex 5.2.3 Abscess Formation . 25 and the Hilus . 14 5.2.4 Healing with Fibrosis and Scar Formation 25 4.1.3 The Recirculation of Lymphocytes . 14 5.2.4.1 Examples.................... 25 X Contents 5.3 Chronic Inflammation . 26 7.4.3 Pathogenesis.................. 43 5.3.1 Immune Granulomas............. 26 7.4.4 Examples.................... 43 5.3.1.1 The Tuberculous Granuloma . 27 7.4.5 Differential Diagnosis . 43 5.3.1.2 Sarcoidosis ................... 28 7.5 Category V: Lymphocytic/Monocytic Arterial 5.3.1.2.1 Example . 28 Vasculitis.................... 44 5.3.2 Foreign Body Granuloma . 28 7.5.1 Clinical Appearance . 44 5.3.3 Relevant Investigations............ 28 7.5.2 Histopathologic Appearance......... 44 5.4 Angiogenesis . 28 7.5.3 Examples.................... 44 5.5 Cell Division.................. 29 7.5.4 Comment . 49 References ......................... 30 7.6 Category VI: Granulomatous Neutrophilic Arterial Vasculitis............... 49 7.6.1 Clinical Appearance . 49 6 Cell Death in the Living Body 7.6.2 Histopathologic Appearance......... 49 7.6.3 Examples.................... 50 6.1 Accidental Cell Death . 31 7.6.4 Comment . 50 6.2 Apoptosis . 31 7.7 Category VII: Mixed Group . 50 6.2.1 Apoptosis in Embryonic Development . 32 7.7.1 Erythema Elevatum Diutinum . 51 6.2.2 Apoptosis in Postnatal Life.......... 33 7.7.1.1 Clinical Appearance . 53 6.2.3 Relevant Investigations............ 33 7.7.1.2 Histopathologic Appearance......... 53 6.2.4 Apoptosis and the Skin............ 33 7.7.1.3 Example . 53 References ......................... 34 7.7.1.4 Comment . 53 7.7.2 Granuloma Faciale . 55 7.7.2.1 Clinical Appearance . 55 7 Vasculitis 7.7.2.2 Histopathologic Appearance......... 55 7.7.2.3 Pathogenesis.................. 55 7.1 Category I: Neutrophilic Venular Vasculitis 35 7.7.2.4 Example . 55 7.1.1 Clinical Appearance . 37 7.7.2.5 Comment . 55 7.1.2 Histopathologic Appearance......... 37 7.7.3 Angiolymphoid Hyperplasia with 7.1.3 Pathogenesis.................. 37 Eosinophilia . 55 7.1.4 Examples.................... 38 7.7.3.1 Example . 56 7.1.5 Variants of Leukocytoclastic Vasculitis . 38 7.7.3.2 Comment . 57 7.1.5.1 Henoch-Schönlein Purpura . 38 7.7.4 Bacillary Epithelioid Angiomatosis . 57 7.1.5.2 Infantile Acute Hemorrhagic Edema of the 7.7.4.1 Examples.................... 59 Skin....................... 39 7.7.5 Comment . 59 7.1.5.3 Urticarial Vasculitis.............. 39 7.8 Nomenclature . 61 7.1.5.4 Recurrent Cutaneous Necrotizing 7.9 Conclusion................... 62 Eosinophilic Vasculitis . 40 References ......................... 63 7.1.5.5 Pustular Vasculitis of the Hands....... 40 7.1.6 Differential Diagnosis . 40 7.2 Category II: Lymphocytic Venular 8 Skin Lesions due to Abnormalities Vasculitis.................... 40 in Blood Components 7.2.1 Clinical Appearance . 40 7.2.2 Histopathologic Appearance......... 40 8.1 The Normal Coagulation/Fibrinolytic Balance 7.2.3 Pathogenesis.................. 40 in the Coagulation System.......... 65 7.2.4 Examples.................... 40 8.2 Disseminated Intravascular Coagulation . 65 7.2.5 Differential Diagnosis . 41 8.2.1 Example . 66 7.3 Category III: Granulomatous Venular 8.3 Thrombotic-Thrombocytopenic Purpura/ Vasculitis.................... 41 Hemolytic-Uremic (TTP/HUS) Syndrome 66 7.3.1 Example . 42 8.3.1 Examples.................... 66 7.4 Category IV: Neutrophilic Arterial 8.3.2 Comment . 67 Vasculitis.................... 42 8.4 Hypercoagulability of Minor Severity . 68 7.4.1 Clinical Appearance . 43 8.4.1 Examples.................... 68 7.4.2 Histopathologic Appearance......... 43 8.4.2 Comment . 70 XI 8.5 Skin Necrosis Induced by Treatment with 13.1.2 Histopathologic Appearance......... 88 Warfarin . 70 13.1.3 Relevant Investigations............ 90 8.6 Cryoglobulinemia............... 70 13.1.4 Examples.................... 91 8.6.1 Example . 71 13.1.5 Comment .
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