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Year : 2017  |  Volume : 62  |  Issue : 4  |  Page : 437-439
Multiple noduloulcerative lesions over extremities: Can cytology be diagnostic?


Department of Pathology, Sonoscan Healthcare, Malda, West Bengal, India

Date of Web Publication10-Jul-2017

Correspondence Address:
Krishnendu Mondal
C/o Barendra Nath Mondal, Fularhat, P. O. and P. S. Sonarpur, South 24 Parganas - 700 150, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_460_16

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How to cite this article:
Mondal K, Mandal R. Multiple noduloulcerative lesions over extremities: Can cytology be diagnostic?. Indian J Dermatol 2017;62:437-9

How to cite this URL:
Mondal K, Mandal R. Multiple noduloulcerative lesions over extremities: Can cytology be diagnostic?. Indian J Dermatol [serial online] 2017 [cited 2020 May 25];62:437-9. Available from: http://www.e-ijd.org/text.asp?2017/62/4/437/210086


A 51-year-old man presented with numerous mobile, skin-colored, tender, subcutaneous nodules over the extensor aspects of his superior and inferior extremities for the past 2 years. These nodules measured between 1 and 5 cm in diameter. Some of the right pretibial lesions were ulcerated and oozed chalky substances. The associated small joints of hands and feet were disfigured [Figure 1]. Their mobility was partially compromised. However, the skin overlying these distorted peripheral joints lacked any inflammatory changes. On further interrogation, he also recalled few episodes of asymmetric arthritis involving hands and feet during the past 15 years. Family history of gout as well as personal history of diabetes, hypertension, alcoholism, purine-rich diet, and exposure to chemicals/heavy metals was negative.
Figure 1: Clinically, skin-colored, subcutaneous nodules (thin arrows) in the elbows, forearms (a), wrists, hands (b), shins, ankles, and feet, along with disfigurement of respective small joints (thick arrow) (c)

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Plain skiagram detected only soft tissue swellings [Figure 2]. Serum biochemical investigation revealed ↑uric acid (13.8 mg/dl, normal: 4–7 mg/dl), ↑urea (92 mg/dl, normal: 10–50 mg/dl), and ↑creatinine (1.8 mg/dl, normal: 0.5–1.2 mg/dl). Liver function test, urinalysis, and serum electrolytes remained within normal reference ranges. Rheumatoid factor was negative. Fine-needle aspiration cytology from the nodules and also the cytological preparation with chalky discharges from the ulcers expressed amorphous fluffy masses of brown-colored crystals with foreign body reaction. Rare polymorphs and histiocytes were present. The morphology of these crystals was best visualized under higher magnification at the periphery of crystallized clumps as well as in dispersed crystals lying singly. Structurally, these crystals appeared long and extremely fine, sharply pointed at both ends, resembling the shape of a needle [Figure 3]. No other cellular elements were found within any of the smears.
Figure 2: Radiologically, soft tissue swellings (arrows) around the right (a) and left (b) elbow joints

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Figure 3: Cytologically, clumps of brown-colored crystals (H and E stain, ×100), with (lower inset) foreign body giant cell reaction (Leishman stain, ×400), on magnification, (upper inset) sheaves of characteristic needle-shaped crystals (Leishman stain, ×400)

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   Question Top


What is your diagnosis?



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   References Top

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Bones HA. Joints and soft tissue tumors. In: Kumar V, Abbas AK, Aster JC, editors. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Philadelphia: Elsevier; 2014. p. 1214-7.  Back to cited text no. 3
    
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Kelley WN, Schumacher HR Jr. Crystal-associated synovitis. In: Kelley WN, editor. Textbook of Rheumatology. 4th ed. Philadelphia: Saunders; 1993. p. 291-336.  Back to cited text no. 4
    
5.
Elder DE, editor. Lever's Histopathology of the Skin. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 438-9, 791-810, 1057-99.  Back to cited text no. 5
    
6.
Koss LG, Melamed MR, editors. Koss' Diagnostic Cytology and Its Histopathologic Bases. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 1290-1.  Back to cited text no. 6
    
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Gupta A, Rai S, Sinha R, Achar C. Tophi as an initial manifestation of gout. J Cytol 2009;26:165-6.  Back to cited text no. 7
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Walke V, Ramraje S, Jadhao V. Cytodiagnosis of gouty tophus. Cytojournal 2013;10:11.  Back to cited text no. 8
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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