The American Society of Dermatopathology

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Interactive Case Study - September 2023

A Painful Indurated Plaque on the Shin

Jill I. Allbritton, MD; Michael Lewin-Smith, MD; Stacy Strausborger, MFS; Walter L. Rush, MD

Question 1:

A 49-year-old woman presented with right leg pain, intermittent swelling and rash of the right lower leg for 6 months without systemic symptoms. Her history is significant for cerebral vascular incident as an infant resulting in right sided weakness, and leg length discrepancy due to right ankle surgery in 1977.  In 2008, an unknown type of silicone was injected to add bulk to her right calf.  Erythematous indurated non-blanching plaques are present on her anterior right thigh and shin with minimal edema of right lower leg. Ultrasound was negative for deep venous thrombosis.
A punch biopsy was obtained from the shin, figs. 1-2.

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Figure 1: 

Figure 2: 

Figure 3: 
Scanning electron microscopy with energy dispersive x-ray analysis (SEM-EDXA). (a) Low magnification SEM image of the tissue section, the white box corresponds to (b), the higher magnification region than was mapped by EDXA. (c) Elemental maps showing the distribution of the elements silicon (Si), oxygen (O), phosphorus (P), and carbon (C).

Figure 4: 
Fourier transform infrared spectroscopy (FTIR). (a) Reflected light image of the region of interest, the red box indicates where the IR spectrum was collected. (b) IR spectra from the specimen with comparison to reference spectra of poly(dimethylsiloxane), commonly known as silicone, and tissue protein.

What is the best diagnosis?