HYPOTHYROIDISM

Results from -------------

1. IDIOPATHIC HYPOTHYROIDISM ----------- Fibrosis and destruction of the thyroid gland.
2. HASHIMOTO’S THYROIDITIS----------------- Marked lymphocytic infiltration of the gland and destruction

Clinical features -----------

1. Skin -----
 MYXEDEMA -------------- Doughy generalized non pitting edema. This presents as a PUFFY FACE with
thickening of lips, broadening of nose and macroglossia.
 Coldness of the skin ----------------- due to low BMR
 Dryness of skin due to decreased sweat.
 Paleness of the skin -------------- due to a combination of anemia, decreased blood supply and increased
deposition of GAGs in the dermis
 Yellowish hue due to hypercarotenemia ----------- in palms, soles and nasolabial folds.
 Poor wound healing
2. Hair ----
 Sparce and brittle most noticeable in the lateral eyebrows, beard, axilla and pubes.
3. Nail
 Grow slowly and brittle
4. Sweating ----------- Decreased.
5. Acanthosis nigricans.

HYPERCORTISOLISM
Results from:
1. Adrenocortical hyperplasia
2. Adenoma or carcinoma of the adrenal cortex
3. Iatrogenic (glucocorticoid therapy)
4. pituitary ACTH secreting adenoma.

Manifestations are -----------------

1. FAT REDISTRIBUTION ----------- with increased fat deposition in the supraclavicular area, buffalo hump, moon
facies, protuberant abdomen. The face is puffy and telangiectatic.
2. EASY BRUISING.
3. DEVELOPMENT OF PETECHIAE AND ECCHYMOSES.
4. IMPAIRED WOUND HEALING.
5. CUTANEOUS STRIAE ---------------- BROAD AND PURPLE.
6. CUTIS MARMORATA.
7. DUE TO EXCESS ANDROGENS-----------
 Acne vulgaris
 Hirsutism
 Male pattern baldness.
8. HYPERPIGMENTATION ------------------ due to excess of ACTH.

ADDISON’S DISEASE
Results from ----------
1. Autoimmune disorders
2. Chronic infections
3. Metastatic tumors
4. Vascular phenomenon
5. Prolonged glucocorticoid therapy

Clinical features ----------

1. Hyperpigmentation ---------- it is one of the earliest signs of Addison’s disease. The pigmentation occurs due
to compensatory excess production of ACTH by the pituitary. It manifests as -----------
 Suntan persisting well into the winter
 Marked darkening of folds, frictional areas and palmer creases
 Nevi may darken
 Lentigo like lesions may develop
 Darkening of hair
 Longitudinal pigmented bands in the nails.
2. Vitiligo is present in 15%.
3. Loss of body hair especially in the axillae in women due to the loss of adrenal androgens.
 GRANULOMA

Granulomatous inflammation is a distinctive type of chronic inflammatory reaction in which the predominant cell
type is an epitheloid cell which is an activated macrophage with a modified epithelial like appearance.
A granuloma is a focal area of granulomatous inflammation. This is often surrounded by a collar of mononuclear
leucocytes principally lymphocytes and occasionally plasma cells.
In H&E, the epitheloid cells have a PALE PINK GRANULAR CYTOPLASM WITH INDISTINCT CELL BOUNDARIES OFTEN
APPEARING TO MERGE INTO ONE ANTOTHER. THE NUCLEUS IS LESS DENSE THAN THAT OF A LYMPHOCYTE
(VESICULAR), IS OVAL OR ELONGATED AND MAY SHOW FOLDING OF THE NUCLEAR MEMBRANE. Older granulomas
have a enclosing rim of fibroblasts and CT. frequently the epitheloid cells fuse to form giant cells in the periphery or
sometimes in the centre of the granuloma. The giant cells comprise of large mass of cytoplasm containing 20 or more
small nuclei arranged either peripherally (LANGHAN’S GIANT CELL) or haphazardly (FOREIGN BODY GIANT CELL).

HISTOLOGICAL CLASSIFICATION:

1. EPITHELOID GRANULOMA WITHOUT NECROSIS

 Sarcoidosis
 Tuberculoid leprosy
 Tuberculosis --- LUPUS VULGARIS
 Lichen scrofulosorum
 Foreign body granuloma
 Chronic cutaneous leishmaniasis
 Granulomatous rosacea
 Cheilitis granulomatosa (MIESCHER MELKERSSON ROSENTHAL)
 Allergic granulomatous reaction ---- silica, zirconium, aluminium, beryllium
 Collagen inplant granuloma

2. EPITHELOID GRANULOMA WITH NECROSIS

 Tuberculosis
 Non tuberculous mycobacteria
 Tertiary syphilis
 Cryptococcosis
 Histoplasmosis

3. PALISADING GRANULOMA

 Granuloma annulare
 Rheumatoid nodule
 NLD
 Rheumatic nodule
 Actinic granuloma
 Occasional examples of deep fungal infection

4. MIXED CELL GRANULOMA (lymphocytes and plasma cells are present alongwith epitheloid cells which may
form loose clusters)

 Keratin granuloma (ruptured cyst, folliculitis)

 Sporotrichosis
 Chromomycosis
 Blastomycosis
 Phaeohyphomycosis
 Coccidiodomycosis
 Candidial granuloma
 Cryptococcosis
 Cat scratch disease
 Non tuberculosis mycobacteria.
 Persistent arthropod bite

ANOTHER CLASSIFICATION:
1. Tuberculoid granuloma
2. Sarcoidal granuloma
3. Palisading granuloma
 4. Foreign body granuloma ------------ can induce both allergic and non allergic type of granuloma
 ALLERGIC ------------------- sea urchin, beryllium, zirconium, silica, tattoo and insect bite.
 NON ALLERGIC ------------ Paraffin, silica, talc, starch, cacti
5. Suppurative granuloma.

LICHENOID DERMATITIS

Lichenoid inflammation is a diffuse band like infiltrate of small lymphocytes clustered about a dermal-
epidermal junction and obscuring the interface. Apoptotic or necrotic keratinocytes are often present.

LICHENOID DERMATITIS, LYMPHOCYTES EXCLUSIVELY /PREDOMINANT (mixed with plasma cells and
eosinophils)------------------
1. LP
2. Benign lichenoid keratoses
3. PLC
4. LE----------- lichenoid forms
5. MCTD
6. GVHD, lichenoid stage
7. EM
8. PLEVA, early stages
9. parapsoriasis/mycosis fungoides, patch/plaque stage
10. Sezary syndrome
11. Pigmented purpuric dermatitis, lichenoid type (Gougerot Blum)
12. Lichen striatus
13. Lichenoid tattoo reaction
14. secondary syphilis

LICHENOID DERMATITIS, EOSINOPHILS PRESENT -----------------

1. Lichenoid drug eruptions
2. Arthropod bite reactons
3. Histiocytosis X
4. Mastocytosis/Telangiectasia macularis eruptive perstans

LICHENOID DERMATITIS, PLASMA CELLS PRESENT -----------

1. Lichenoid actinic keratoses
2. Bowen’s disease
3. Erythroplasia of Queyret
4. Secondary syphilis
5. zoon’s plasma cell balantitis

LICHENOID DERMATITIS WITH MELANOPHAGES

1. Post inflammatory hyperpigmentation
2. regressed melanocytic lesion

LICHENOID DERMATITIS, HISTIOCYTES PREDOMINANT

1. Lichen nitidus
2. Actinic reticuloid
3. Chronic actinic dermatitis
4. Histiocytosis X

LICHENOID DERMATITIS, MAST CELLS PREDOMINANT

1. Urticaria pigmentosa.