Back issues No.1 - 2013 / Resident Forum  

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Rapidly progressing, painful, ulcerative changes in long-standing psoriasiform plaques in a 46-year-old man
Sheng-Yiao Lin, Tsu-Man Chiu, Kuo-Chia Yang, Chuan-Cheng Wang, Ming-Ching Shen, Pei-Yi Chu, Yueh-Min Lin

A 46-year-old man was admitted to a community hospital with fever and rapidly progressing, painful, ulcerative skin lesions. He was transferred to our hospital for further examination. According to his medical history, he had been diagnosed with psoriasis, but this was not confirmed by a skin biopsy. The generalized pruritic plaques on his trunk and extremities had waxed and waned for several years but had exacerbated during the previous year. Skin examination on admission showed diffuse redness with periorbital, paranasal, and perioral sparing with multiple coalescent annular plaques on the trunk and extremities. Some of these lesions were indurated, others were crusted. Ulcerative plaques were present on the dorsum of the patient's right hand and soles (Figures 1A and 2A). A few inguinal lymph nodes were palpable on each side. The histopathological examination of specimens obtained from his left elbow, left thigh, and an inguinal lymph node revealed dense infiltrations of atypical medium-sized lymphocytes with nuclear pleomorphism. Eosinophils were identified in the dermis (Figure 3) of the specimens from the elbow and thigh and in the perifollicular zones of the lymph node. Immunohistochemical staining showed that these infiltrates were positive for CD2, CD3, CD4, CD5, CD8, and CD30 and negative for CD10, CD20, CD21, CD23, Epithelial Membrane Antigen (EMA), and Anaplastic Lymphoma Kinase (ALK). In situ hybridization for Epstein-Barr virus-encoded RNA (EBER) produced negative findings. Other significant laboratory data included the following: white cell count, 23,410 cells/μL (normal: 3500–9100/μL); band form, 35% (normal: 0–3%); total Immunoglobulin E (IgE), 574 IU/mL (normal for adults: <87 IU/mL); LDH, 461 U/L (normal: 98–192 U/L); ferritin, 387.3 ng/mL (normal for men: 23.9–336.2 ng/mL). The results of the bone marrow biopsy were normal. Abdominal computed tomography (CT) and bone scan revealed the lack of involvement in the internal organs. Human T cell lymphotropic virus I (HTLV)-related lesions were suspected; therefore, serological tests were performed. Enzyme-linked immunosorbent assay (ELISA) screening test revealed positivity to anti-HTLV I/II, and reactivity to HTLV type I (HTLV-I) was confirmed by Western blot analysis.
Based on the abovementioned findings, a diagnosis of adult T cell lymphoma was made.

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