Epstein-Barr virus (EBV) infection can rarely present as painful genital ulcers, mostly in young female adolescents. Typically diagnosed by clinical findings, EBV vulvar ulceration (EBVVU) is rarely biopsied. Herein, the authors report the histopathology in 8 biopsies from 7 EBVVU patients, all serologically confirmed for acute (4/7) or reactivated-chronic (3/7) EBV infection. The 7 women all presented with 1 or more painful, punched-out vulvar ulcers. Only patients with acute EBV infection showed other clinical findings: fever and/or atypical lymphocytosis affected 75% (3/4); lymphadenopathy in 50%; and malaise/fatigue, dysuria and/or hepatomegaly in 25%. All reactivated-chronic EBVVU had a solitary ulcer, and 2 had history of a similar episode of vulvar ulceration (aphthosis). Histopathologically, lymphocytic arteritis was identified in 88% (7/8); a submucosal scar was found in the eighth specimen. Other histopathologies included venulitis (62%), endarteritis obliterans (38%), thrombosis (25%), neutrophilic sebaceous adenitis (25%), and mucosal lymphoid hyperplasia (12%). Dense angiocentric CD3 CD4 T-cell lymphocyte-predominant infiltrates were found, regionally or diffusely. In 2 specimens, neutrophils compromised half of the infiltrate. Minor components of CD8, CD20, and CD30 lymphocytes, CD123 plasmacytoid monocytes, CD68 macrophages, and plasma cells were present. Small-vessel endothelium and smooth muscle adjacent to the ulcers faintly expressed cytoplasmic EBV latent membrane protein-1 (LMP1). In situ hybridization for early EBV mRNA (EBER) identified rare solitary or scattered clustered positive lymphocytes in 38%. Polymerase chain reaction for EBV DNA was positive in one EBER positive biopsy. EBV infection has been documented in muscular vessel vasculitis. Based on the aforementioned, EBVVU appears to be the consequence of localized lymphocytic arteritis.

Lymphomatoid papulosis (LyP) is a cutaneous CD30-positive T-cell lymphoproliferative disorder that occurs primarily in adults and presents with crops of papules that become necrotic and spontaneously regress. It is classified according to the histopathologic findings; currently recognized subtypes include A, B, C, D, and E. LyP is uncommon in children. Herein we describe a child with an unusual clinical presentation of LyP type D and review the literature of reported cases in children.

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Leukocytoclastic vasculitis (LCV), also known as small-vessel cutaneous vasculitis, is rarely seen in the setting of staphylococcal infection without bacteremia. Here, we present a case of LCV in a 61-year-old male with chronic staphylococcal osteomyelitis without any evidence of bacteremia. The rash resolved with the treatment of osteomyelitis. As seen in this case, local infection should be considered in the differential diagnosis of LCV even when there is no evidence of bacteremia.