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Subspecialties Histology, Microbiology and immunology

Case of the Month

Question: A 62-year-old man undergoes biopsy of a vocal fold nodule during workup for dysphonia.

What might be discovered upon review of the patient's history?

a. An 80-pack-year smoking history
b. Distant motor vehicle accident
c. History of multiple myeloma
d. Treatment for dysphonia a decade prior to biopsy

Figure 1. 10x, crystalloid structures with associated granulomatous inflammation and giant cells

Figure 2. 20x, crystalloid structures with associated granulomatous inflammation and giant cells

Figure 3. 20x, crystalloid structures under polarized light

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Answer to May/June's Case of the Month

B. Warty dyskeratoma

Histopathologic evaluation reveals a cup-shaped squamous proliferation with prominent acanthosis, dyskeratosis, and focal papillary structure formation. These findings are most consistent with a warty dyskeratoma. Squamous cell carcinoma and actinic keratosis can both demonstrate dramatic acantholysis, mimicking this lesion. However, warty dyskeratoma shows classic cup-shaped morphology and lacks the significant cytologic atypia of squamous cell carcinoma or actinic keratosis. Darier disease is a skin disorder that presents as multiple hyperkeratotic papules. Microscopic examination of a Darier disease papule will show acantholysis and dyskeratosis, histologically similar to warty dyskeratoma, but with an overall flat (not endophytic) architecture. Darier disease may also show mutations in ATP2A2, distinguishing it from warty dyskeratoma and another histologic mimic, Grover disease. 

Submitted by Megan C. Smith, Resident in Anatomic and Clinical Pathology, Vanderbilt University Medical Center, Department of Pathology, Microbiology, and Immunology, Nashville, TN, USA

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