SKIN March 2019 Volume 3 Issue 2 Copyright 2018 The National Society for Cutaneous Medicine 109 SHORT COMMUNICATIONS A female with thick intertriginous vegetative plaques Brandon T. Beal, MD1; Hannah Cundall BS2; Anthony P. Fernandez, MD, PhD3 1Department of Dermatology, Cleveland Clinic, Cleveland, OH 2School of Medicine, Case Western Reserve University, Cleveland, OH 3Department of Dermatology, Cleveland Clinic, Cleveland, OH A woman in her 80’s presented with exudative, malodorous, and vegetative plaques in the bilateral axillary vault, groin, and right inframammary fold for 18 months (Figure 1). Her past medical history was significant for a remote history of breast cancer treated with unilateral left mastectomy without recurrence. She denied history of inflammatory bowel disease (IBD) and gastrointestinal symptoms. Oral and ocular examinations were unremarkable. Work-up was notable for a peripheral eosinophilia (24.1%). Indirect immunofluorescence (IF) for IgG and IgG4 antibodies and enzyme- linked immunosorbent assay (ELISA) for desmoglein (Dsg) 1 and 3 antibodies were negative. A 4-mm punch biopsy was obtained (Figure 2). Direct immunofluorescence (DIF) to evaluate for pemphigus vegetans revealed weak granular deposition of complement C3 at the basement membrane zone. Pyodermatitis vegetans (PDV) is a rare cutaneous inflammatory disease characterized by thick intertriginous vegetative plaques and peripheral eosinophilia (1). Pyostomatitis vegetans is characterized by pustular and vegetative plaques of the oral mucosa, and is considered to be the oral equivalent of PDV. Pyodematitis-pyostomatitis vegatans is often associated with IBD, in particular ulcerative colitis (2,3). PDV can be difficult to distinguish from pemphigus vegetans, a rare autoimmune bullous disease, since the two disorders share many clinical and histologic features. Figure 1: Plaques present in the inframammary fold. CASE REPORT DISCUSSION SKIN March 2019 Volume 3 Issue 2 Copyright 2018 The National Society for Cutaneous Medicine 110 Figure 2: Lesional hematoxylin-eosin staining demonstrated mild spongiosis with abundant eosinophils, prominent epidermal acanthosis, intraepidermal microabscesses with eosinophils, and a dense perivascular and interstitial inflammatory infiltrates with eosinophils and neutrophils. Common histologic findings in PDV include intraepidermal eosinophilic microabscesses, eosinophilic and neutrophilic infiltrates, and acanthosis (1,4). Unlike PDV, pemphigus vegetans is not associated with IBD (5). DIF and IF are crucial to distinguish between these disorders (4). Pemphigus vegetans DIF demonstrates IgG and C3 epidermal deposits and IF or ELISA reveals IgG antibodies against Dsg 3 (4). In summary, we present a case of PDV without mucosal involvement and not associated with IBD. This case highlights a rare disease entity whose clinical and histologic features are important for dermatologists and dermatopathologists to be knowledgeable about. Conflict of Interest Disclosures: None. Funding: None. Corresponding Author: Brandon T. Beal, MD Department of Dermatology, Cleveland Clinic Cleveland, OH bealb@ccf.org References: 1. Matias F, Rosa D, Carvalho M, Castanon MC. Pyodermatitis-pyostomatitis vegetans: case report and review of medical literature. An Bras Dermatol 2011; 86 (4 Suppl): S137-40. 2. Clark L, Tolkachjov S, Bridges A, Camilleri M. Pyostomatitis vegetans (PSV)- pyodermatitis vegetans (PDV): A clinicopathologic study of 7 cases at a tertiary referral center. JAAD 2016; 75: 578-584. 3. Dodd EM, Howard JR, Dulaney ED, Rosenthal SI, Wanna MR, Farah RS. Pyodermatitis-pyostomatitis vegetans associated with asymptomatic inflammatory bowel disease. International Journal of Dermatology 2017. 4. Nico M, Hussein T, Aoki V, Lourenco S. Pyostomatitis vegetans and its relation to inflammatory bowel disease, pyoderma gangrenosium, pyodermatitis vegetans, and pemphigus. Journal of Oral Pathology & Medicine 2012; 584-588. 5. Nigen S, Poulin Y, Rochette L, Lévesque MH, Gagné E. Pyodermatitis-pyostomatitis vegetans: two cases and a review of the literature. J Cutan Med Surg. 2003; 7: 250-5. https://www.ncbi.nlm.nih.gov/pubmed/?term=Dodd%20EM%5BAuthor%5D&cauthor=true&cauthor_uid=28474357 https://www.ncbi.nlm.nih.gov/pubmed/?term=Howard%20JR%5BAuthor%5D&cauthor=true&cauthor_uid=28474357 https://www.ncbi.nlm.nih.gov/pubmed/?term=Dulaney%20ED%5BAuthor%5D&cauthor=true&cauthor_uid=28474357 https://www.ncbi.nlm.nih.gov/pubmed/?term=Dulaney%20ED%5BAuthor%5D&cauthor=true&cauthor_uid=28474357 https://www.ncbi.nlm.nih.gov/pubmed/?term=Rosenthal%20SI%5BAuthor%5D&cauthor=true&cauthor_uid=28474357 https://www.ncbi.nlm.nih.gov/pubmed/?term=Wanna%20MR%5BAuthor%5D&cauthor=true&cauthor_uid=28474357 https://www.ncbi.nlm.nih.gov/pubmed/?term=Farah%20RS%5BAuthor%5D&cauthor=true&cauthor_uid=28474357