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E-IJD® - CORRESPONDENCE
Year : 2021  |  Volume : 66  |  Issue : 4  |  Page : 447
Ulcerated Nodule over a Laproscopic Scar: An Unusual Presentation of Cutaneous Plasmacytoses?


1 Department of Dermatology, Venereology and Leprology, AIIMS, Jodhpur, Rajasthan, India
2 Department of Pathology, AIIMS, Jodhpur, Rajasthan, India

Date of Web Publication17-Sep-2021

Correspondence Address:
Deepak Vedant
Department of Pathology, AIIMS, Jodhpur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_614_20

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How to cite this article:
Bains A, Vedant D, Elhence P, Alam A. Ulcerated Nodule over a Laproscopic Scar: An Unusual Presentation of Cutaneous Plasmacytoses?. Indian J Dermatol 2021;66:447

How to cite this URL:
Bains A, Vedant D, Elhence P, Alam A. Ulcerated Nodule over a Laproscopic Scar: An Unusual Presentation of Cutaneous Plasmacytoses?. Indian J Dermatol [serial online] 2021 [cited 2021 Dec 3];66:447. Available from: https://www.e-ijd.org/text.asp?2021/66/4/447/326131




Dear Editor

Primary cutaneous plasmacytoses (PCP) is a rare benign cutaneous disorder characterised by polyclonal plasma cell proliferation in the skin, in absence of underlying disease. It usually has a chronic, benign course, but a few cases may progress to systemic plasmacytosis.[1]

An 18-year-old female presented with a solitary asymptomatic growth on an old laproscopic scar located over suprapubic area for the last 3 months. Laproscopic scar was due to appendicectomy done 5 years back. Patient denied history of trauma, insect bite and any systemic symptoms. Cutaneous examination revealed single well defined erythematous ulcerated nodule of size approximately 2 cm in diameter with hyperpigmented margins over suprapubic area [Figure 1]. Mucosa was not involved. There was no lymphadenopathy or hepatosplenomegaly. Skin biopsy from lesion revealed acanthosis and elongated rete ridges. The dermis showed dense perivascular and periadnexal aggregates and sheets of chronic inflammatory infiltrate comprising predominantly of plasma cells. There was no atypia. [Figure 2]a and [Figure 2]b. Immunohistochemistry showed no restriction of either kappa or lambda light chain (1:1 positivity) [Figure 3]a and [Figure 3]b. Giemsa, Ziehl Neelsen, PAS, GMS, Gram stain were negative. Complete blood count, liver and renal function tests, and total protein levels, lactate dehydrogenase level were within normal limits. Serum protein electrophoresis was normal with absence of M band and serum immunoglobulin levels were within normal range. Urine for Bence-Jones protein was negative. Serological tests for syphilis and HIV were negative. Ultrasonography of abdomen and thoracoabdominal computed tomography were also normal. Based on the above findings, a diagnosis of primary cutaneous plasmacytosis was made. Clonality analysis was not done because of non-availability and financial constraints. The patient was started on topical clobetasol propionate 0.05% cream twice a day. This was followed by mild decrease in size of lesion at 3 weeks and subsequently lesion was excised.
Figure 1: Solitary ulcerated nodule with hyperpigmented margins over suprapubic area

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Figure 2: (a): Skin biopsy showed acanthosis and elongated rete ridges. The dermis shows dense perivascular and periadnexal aggregates and sheets of chronic inflammatory infiltrate comprising predominantly of plasma cells (H and E, 10X). (b): High power view revealed periadnexal aggregates of plasma cells. (H and E, 40X)

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Figure 3: Immunohistochemistry shows no restriction of either kappa (a) (40x) or lambda light chain (1:1 positivity) (b) (10X)

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The exact etiopathogenesis of PCP is still unknown. It is postulated that there is reactive proliferation of polyclonal plasma cells in response to some unknown stimuli, which includes trauma, infections or malignancies.[2] Genetic polymorphism may result in dysregulated production of IL–6 which induces B – cell proliferation and differentiation to plasma cells.[1] PCP usually presents as multiple red-to-dark-brown non scaly macules, papules, and plaques over trunk, face, the nape of the neck and axillae.[1] Isolated benign PCP has been described in children as a distinct entity.[3] Ulcerated type of PCP is very rare and only 4 cases have been described in the literature to the best of our knowledge [Table 1].[1],[2],[4],[5]
Table 1: Cases of Cutaneous plasmacytoses in which ulceration was reported.[1],[2],[4],[5]

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Other conditions which may present with plasma cell rich infiltrate in skin are primary cutaneous marginal zone b-cell lymphoma, cutaneous plasmacytoma, multicentric castleman's disease (plasma cell variant), lupus erythematosus, scleroderma, secondary syphilis, lyme's disease, leishmaniasis, cutaneous b-cell lymphomatoid hyperplasia, nodular amyloidosis etc.[5] Differential diagnoses of cutaneous plasmacytoses is discussed in [Table 2].[6] There are no standard treatment guidelines. Various modalities used are topical and systemic corticosteroids, tacrolimus, psoralen ultraviolet A, photodynamic therapy, and pulsed dye laser with varying success.[1],[7] The index case was unique because of its atypical clinical presentation as well as location of lesion over suprapubic laparoscopic scar.
Table 2: Differential diagnoses of cutaneous plasmacytoses.[6]

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Dautriche CN, Van Driessche F, Chen L, Brinster N, Marmon S. Ulcerative cutaneous plasmacytosis. JAAD Case Rep 2019;5:540-2.  Back to cited text no. 1
    
2.
Antonio AM, Alves JV, Coelho R, Bartolo E. Solitary ulcerated plaque on the face - An unusual presentation of cutaneous plasmacytosis? An Bras Dermatol 2017;92:410-2.  Back to cited text no. 2
    
3.
Gilliam AC, Mullen RH, Oviedo G, Bhatnagar R, Smith MK, Patton DF, et al. Isolated benign primary cutaneous plasmacytosis in children: two illustrative cases. Arch Dermatol 2009;145:299-302.  Back to cited text no. 3
    
4.
Cerottini JP, Guillod J, Vion B, Panizzon RG. Cutaneous plasmacytosis: An unusual presentation sharing features with POEMS syndrome? Dermatology 2001;202:49-51.  Back to cited text no. 4
    
5.
Khullar G, Narang T, De D, Chougule A, Handa S. Isolated benign primary cutaneous plasmacytosis in an adult Indian male. Dermatol Online J 2016;22:13030/qt6tb095tb.  Back to cited text no. 5
    
6.
Walsh NM, Kutzner H, Requena L, Cerroni L. Plasmacytic cutaneous pathology: A review. J Cutan Pathol 2019;46:698-708.  Back to cited text no. 6
    
7.
Goyal T, Varshney A, Zawar V, Sharma V. Primary cutaneous plasmacytosis: Masquerading as hidradenitis suppurativa. Indian J Dermatol 2016;61:213-5.  Back to cited text no. 7
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