Interactive Case Study - 03- March 2025

37-year-old African American woman presenting with bullous eruption on the extremities

Sena Zengin, MD

Lauren C. Morehead, PhD

Sara C. Shalin, MD, PhD

A 37-year-old African American woman with end-stage renal disease on hemodialysis, diabetes mellitus, and obesity presented with bullous eruption involving her distal extremities. Dermatologic examination showed tense blisters without inflammation on the right dorsal foot and right forearm.

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Figure 1

Figure 2 (PAS)

Figure 3 (C3)

Figure 4(IgG)

Which of the following is the most likely diagnosis?

Bullosis diabeticorum

Bullous pemphigoid

Dermatitis herpetiformis

Epidermolysis bullosa acquisita

Pseudoporphyria

Which of the following is the most important laboratory test in establishing the diagnosis after reviewing the hematoxylin and eosin-stained sections?

Direct immunofluorescence studies

HgA1c levels

Plasma/urine porphyrin levels

Serum anti-tissue transglutaminase levels

Tissue culture

Which of the following patterns of immunoglobulin deposition is most likely expected on direct immunofluorescence in pseudoporphyria?

Granular deposits of IgA in the dermal papillae

Linear deposits of IgA at the basement membrane zone

Linear deposits of IgG and C3 at the basement membrane zone

Negative for immunoglobulin deposition

Perivascular deposition of immunoglobulin and C3

Aye M, Masson EA. Dermatological care of the diabetic foot. Am J Clin Dermatol. 2002; 3:463–74.
Ghosh SK, Bandyopadhyay D, Chatterjee G. Bullosis diabeticorum: A distinctive blistering eruption in diabetes mellitus. Int J Diabetes Dev Ctries. 2009; 29:41–2.
Tull TJ, Benton E. Immunobullous disease. Clin Med (Lond). 2021;21(3):162-165.
Gupta R, Woodley DT, Chen M. Epidermolysis bullosa acquisita. Clin Dermatol. 2012;30(1):60-9.
Mooney E, Falk RJ, Gammon WR: Studies on complement deposits in epidermolysis bullosa acquisita and bullous pemphigoid. Arch Dermatol 1992; 128: pp. 58-60.
Cordova KB, Oberg TJ, Malik M, Robinson-Bostom L. Dermatologic conditions seen in end-stage renal disease. Semin Dial. 2009;22(1):45-55.
Poh-Fitzpatrick MB, Ellis DL. Porphyrialike bullous dermatosis after chronic intense tanning bed and/or sunlight exposure. Arch Dermatol. 1989;125(9):1236-8.
Judd LE, Henderson DW, Hill DC: Naproxen-induced pseudoporphyria: a clinical and ultrastructural study. Arch Dermatol 1986; 122: pp. 451-454.
Cooke NS, McKenna K: A case of hemodialysis-associated pseudoporphyria successfully treated with oral N-acetylcysteine. Clin Exp Dermatol 2007; 32: pp. 64-66.
Haffenden G, Wojnarowska F, Fry L: Comparison of immunoglobulin and complement deposition in multiple biopsies from the uninvolved skin in dermatitis herpetiformis. Br J Dermatol 1979; 101: pp. 39-45.
Shetty VM, Subramaniam K, Rao R. Utility of immunofluorescence in dermatology. Indian Dermatol Online J. 2017;8(1):1-8.
Chorzelski TP, Jablonska S, Beutner EH, Wilson BD. In: Linear IgA bullous dermatosis. Immunopathology of the Skin. 3rd ed. Beutner EH, Chorzelski TP, Kumar V, editors. New York: John Wiley & Sons; 1987. pp. 407–20.
Toonstra, J. (1985). Bullosis diabeticorum. Journal of the American Academy of Dermatology, 13(5), 799–805. doi:10.1016/s0190-9622(85)70226-5
Maynard B, Peters MS. Histologic and immunofluorescence study of cutaneous porphyrias. J Cutan Pathol. 1992;19(1):40-7.

Acknowledgements

Author Profiles

Sena Zengin, MD

University of Arkansas for Medical Sciences

Sena Zengin, MD is a 2nd-year pathology resident at University of Arkansas for Medical Sciences in Little Rock, Arkansas. She is interested in pursuing a career in dermatopathology.

Lauren C. Morehead, PhD

University of Arkansas for Medical Sciences

Lauren Clai Morehead, PhD, is a 7th-year MD/PhD student at the University of Arkansas for Medical Sciences. She previously attended Southern Arkansas University, where she majored in chemistry with a minor in psychology. She is interested in pursuing a career in dermatology and academic medicine.

Sara C. Shalin, MD, PhD

University of Arkansas for Medical Sciences

Sara Shalin, MD, PhD, is a Professor in the Departments of Pathology and Dermatology, the Chair of the Dermatology Department, and Director of the UAMS MD-PhD program at the University of Arkansas for Medical Sciences in Little Rock, Arkansas.

Question:

Interactive Case Study - 03- March 2025

Acknowledgements

Author Profiles

37-year-old African American woman presenting with bullous eruption on the extremities

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