European Journal of Cardiovascular Medicine

Cutaneous vasculitis comprises of different clinical pathological spectrum with some of them leading on to serious multi systemic involvement. Skin biopsy always plays an important first line investigation for the above diagnosis. This study emphasises the role of histopathology in various differential diagnosis of cutaneous vasculitis as the treatment plan differs in each of them. Moreover, the relevance of clinical input is also important for correct diagnosis. The aim of this study is to emphasise the role of histopathology in the differential diagnosis of cutaneous vasculitis and to correlate it with clinicopathological findings.

This study was conducted in the department of Pathology in a teaching hospital of South India. There were 80 skin biopsies which were clinically diagnosed as primary and secondary cutaneous vasculitis. It is a retrospective study over five years. The clinical history and details were collected from the medical records section. The histopathological details were analyzed  by pathologists from the stained haematoxylin and eosin slides

Based on clinical presentation the lesions were classified according to their clinical symptoms and morphological appearance. The parameters used were based on clinical presentation as pustules, bulla, plaques, targetoid lesions, macules, purpuric spots and papules. Histopathological sections there were classified based on the size of the blood vessels, nature of cellular infiltrate, extravasation of RBC’s fibrinoid necrosis. The predominant cellular infiltrate was noted,whether it was neutrophils, eosinophils, lymphocytes or histiocytes.Presence of granulomas, extravasation of RBC’s and fibrinoid necrosis were also noted.

The total numbers of skin biopsies in a 5 year period  were 1835, out of which there were   80 cases of cutaneous vasculitis  .The clinical profile and histopathological study were analyzed on these 80 cases(4%). The clinical profile included  clinical symptoms and presentation, morphological appearance like hyper pigmented or hypo pigmented, multiple or single, papule, purpura, macules, pustules and  bulla. Histopathological classification  was based on size  of the vessel(large vessel, medium vessel or capillaries), nature of cellular infiltrate, extravasation of RBC’s and fibrinoid necrosis.

 Age wise distribution of cutaneous vasculitis showed that there were 26 cases (33%) in the age group of   more than 50 years and for less than 50 years of age,there  were 54 cases (65%). Sex  distribution showed a  slight female predominance with 43cases (54%) and males were 37 cases (46%). Patients who had  painful lesions  were 25 cases (31%) and without painless lesions were seen in 55 cases (69%). The location of the lesion were over the extremities  in 59 cases (75%) and central lesions were noted in  21 cases (25%). Multiple lesions observed  in 58 cases (72%) and single lesions were observed in 22 cases (28%). Some the patients had extra cutaneous manifestations,as seen in  47cases (59%) like hypertension, diabetes mellitus, rheumatoid arthritis, hyperthyroidism. Pure cutaneous manifestations were  seen in 33cases (41%). Purpura  were seen in 25cases (31% ), plaques  in 25cases (31% ), papules in 12 cases (15% ) , macules in7 cases (8% ), pustules in  6 cases (9% ), bulla in 5 cases (6% ).

Histopathological study showed all the 80 cases of cutaneous vasculitis were of small artery vasculitis. Microscopically inflammatory cells around the vessels were  neutrophils as seen in  99 cases (69%), neutrophils with eosinophils in  39 cases (27%), neutrophils with karyorrhexis  were seen in  5cases (4%), others like lymphocytes, plasma cells were rare accounting for 4%.Extravasation of RBC’s were seen in  72  cases(65%) and with fibrinoid necrosis in 38cases (35%)

Figure 1: Left foot showing multiple small hyperpigmented area with purpura,plaques, macules.

Figure 2: Haematoxylin and eosin stain 10x. Skin lined by keratinizing stratified squamous epithelium with adnexal structure and dermis showing some inflammation.

Figure 3: Haematoxylin and eosin stain 100x. Skin with underlying dermis showing showing blood vessels surrounded by inflammatory cells and extravasation of RBC’s

Figure 4: Haematoxylin and eosin stain 100x. The underlying dermis showing skin adnexal structures , blood vessels with fibrinoid necrosis and surround small arteries showing inflammatory cells.

Figure 5: Haematoxylin and eosin stain 400x.Blood vessel in the dermis surrounded by neutrophils, eosinophils

Figure 6: Haematoxylin and eosin stain 400x.Blood vessels showing fibrinoid necrosis with inflammatory cells and karyohexis around the small arteries with extravasation RBC’s.