Ann Dermatol.  2018 Feb;30(1):29-35. 10.5021/ad.2018.30.1.29.

Histopathologic Finding of Perieschar Lesions in Tsutsugamushi Disease Shows Lymphocytic Vasculitis Mimicking Angiocentric Lymphoma

• Jang MS
• Park JB
• Lee KH
• Jang JY
• Yang MH
• Kim JH
• Hwangbo H
• Lee TG
• Suh KS

• KMID: 2399751
• DOI: http://doi.org/10.5021/ad.2018.30.1.29

Abstract

BACKGROUND
Tsutsugamushi disease is an acute, febrile, infectious disease caused by Orientia tsutsugamushi. Several studies investigating the histopathologic findings of eschars in tsutsugamushi disease reported leukocytoclastic vasculitis and neutrophil infiltration as the major findings. However, these findings may result from secondary changes following tissue necrosis. The histopathologic findings of perieschar lesions may be important to understand the primary changes associated with tsutsugamushi disease.
OBJECTIVE
To investigate characteristic histopathologic features of perieschar lesions and suppose the mechanism of vascular pathophysiological changes associated with tsutsugamushi disease.
METHODS
We analyzed histopathological slides of perieschar lesions in 12 patients diagnosed with tsutsugamushi disease.
RESULTS
In the epidermis, exocytosis of mononuclear cells (75.0%) and basal vacuolar changes (66.7%) were frequent. In the dermis, perivascular, interstitial, and perineural mononuclear cell infiltration (100.0%, 83.3%, and 83.3%, respectively), as well as thrombosis (83.3%), atypical lymphocyte infiltration (91.7%), and mitotic figures (83.3%) were commonly seen. Lymphocytic vasculitis and mononuclear cell infiltration around eccrine glands were found in all cases, but eosinophil infiltration was only found in one patient (8.3%). However, the characteristic findings of eschar lesions, such as leukocytoclastic vasculitis and neutrophil infiltration, were not found in perieschar lesions.
CONCLUSION
The major histopathologic findings in the perieschar lesions of tsutsugamushi disease were lymphocytic vasculitis and atypical lymphocytic infiltration, mimicking lymphoma. Therefore, we suggest that this lesion should be added to the list of pseudolymphomas. To observe these characteristic histopathologic features, we also recommend that skin biopsies should be performed on perieschar lesions, not eschar lesions.

Keyword

Angiocentric lymphoma; Histopathologic finding; Lymphocytic vasculitis; Perieschar lesion; Tsutsugamushi disease

MeSH Terms

Biopsy
Communicable Diseases
Dermis
Eccrine Glands
Eosinophils
Epidermis
Exocytosis
Humans
Lymphocytes
Lymphoma*
Necrosis
Neutrophil Infiltration
Orientia tsutsugamushi
Pseudolymphoma
Scrub Typhus*
Skin
Thrombosis
Vasculitis*

Figure

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  Fig. 1 (A) Eschar and maculopapular eruption on anterior chest. (B) Maculopapular eruption on face and neck. (C) Eschar and perieschar erythematous lesions in case 11. Skin biopsy was performed in perieschar erythematous area (circle).

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  Fig. 2 (A) Histopathologic findings show dense infiltration around vessels and eccrine glands in dermis and subcutaneous tissue (H&E, ×40). (B, C) Lymphohistiocytic infiltration around vessels, fibrinoid necrosis (arrow) of vessel wall, thrombus deposition and halo within vessel, and lymphoid dust are shown (H&E, ×400). (D) Vessel wall with hyalinization is rimmed by abundant lymphohistiocytes (H&E, ×200). (E) Vessel lumen with attenuated endothelium (arrow) contains numerous red blood cells (H&E, ×400). (F) Mitotic figure (arrowhead; H&E, ×1,000) and (G) large atypical pleomorphic cells with hyperchromatic nuclei (arrowheads) are shown in dermis (H&E, ×400) (case 5).

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  Fig. 3 (A~C) Immunohistochemically, the majority of infiltrating atypical lymphocytes are CD3-positive T-cells with a predominance of CD4-positive cells over CD8-positive cells (×100). (D~F) Perivascular and interstitial infiltrating cells are negative for CD20 and CD56 and positive for CD68 (case 11) (×100).

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