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An Asymptomatic Verrucous Plaque on the Right Temple of an Adolescent Girl

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

An adolescent girl presented with an asymptomatic slightly reddish verrucous plaque on the right temple. The skin lesion was nail sized when first noticed 1½ years earlier, then gradually developed over the 8 months prior to presentation. The patient denied any associated fevers, weight loss, or night sweats. Physical examination revealed a slightly reddish verrucous mass with translucent papules and plaques on the right temple, about 5 cm in diameter, with surface hemorrhagic crust in the side adjacent to right eyebrow arch (Figure, A). The lesion was nontender with no purulent discharge and no severe necrotic changes. There was no hepatosplenomegaly or superficial lymphadenopathy. Laboratory tests, including blood cell counts, urinalysis, and kidney and hepatic panels, revealed no abnormalities. A skin biopsy was performed and submitted for histopathologic analysis (Figure, B-D).

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D. Primary cutaneous embryonal rhabdomyosarcoma

Histopathologic evaluation revealed papillomatous epidermal hyperplasia and edema of dermal papillae with nested or cordlike distribution of small round blue cells (Figure, B). Most of the tumor cells had round, fusiform, or oval hyperchromatic nuclei, with conspicuous nucleoli and scant amphophilic cytoplasm (Figure, C). Some small, undifferentiated, round, blue, and spindle-shaped cells with scattered, more mature rhabdomyoblasts were also seen in the middle dermis. Immunohistochemical analysis showed positivity for MyoD1 (Figure, D), myogenin, vimentin, and desmin, and negativity for myeloperoxidase, CD45, CK, Ki-67, CD31, CD34, CD1a, CD117, and SOX-10. The pattern of morphology and immunostain expression led to the diagnosis of embryonal rhabdomyosarcoma (ERMS).

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Article Information

Corresponding Author: Tong-Yun Liu, MD, Department of Dermatology, The First Affiliated Hospital of Kunming Medical University, 295 Xichang Rd, Wuhua District, Kunming City 650032, Yunnan Province, China (liutongyun@ydyy.cn).

Published Online: June 8, 2022. doi:10.1001/jamadermatol.2022.2056

Conflict of Interest Disclosures: Dr Liu reported grants from the Department of Science and Technology of Yunnan Province and the Yunnan Provincial Health Commission. No other disclosures were reported.

Funding/Support: This work was supported by the Yunnan Province applied basic research program (No. 2019FE001 [−203]) and Yunnan Province Clinical Center for Skin Immune Diseases (No. ZX2019-03-02).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the patient and her mother for granting permission to publish this information.

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