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CORRESPONDENCE
Year : 2022  |  Volume : 67  |  Issue : 1  |  Page : 84-86
A case of cutaneous T cell lymphoma masquerading as keloidal blastomycosis treated with CHOP regimen


Department of Dermatology, Venereology and Leprosy, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India

Date of Web Publication19-Apr-2022

Correspondence Address:
D Manoharan
Department of Dermatology, Venereology and Leprosy, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_109_21

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How to cite this article:
Reddy DI, Danny GC, Manoharan D, Manoharan K. A case of cutaneous T cell lymphoma masquerading as keloidal blastomycosis treated with CHOP regimen. Indian J Dermatol 2022;67:84-6

How to cite this URL:
Reddy DI, Danny GC, Manoharan D, Manoharan K. A case of cutaneous T cell lymphoma masquerading as keloidal blastomycosis treated with CHOP regimen. Indian J Dermatol [serial online] 2022 [cited 2023 Jun 4];67:84-6. Available from: https://www.e-ijd.org/text.asp?2022/67/1/84/343260




Sir,

A 59-year-old female patient working as a clerk presented with multiple nodules over the right leg. Initially, it started as a violaceous papule and evolved into a nonitchy nodule which rapidly increased in size and number and became exuberant in a period of 2 months. History of pain and photosensitivity were noted. There was no history of fever, trauma, or exposure to chemicals. There was no history of comorbidities or previous surgeries. There was a strong family history of carcinoma. The mother and aunt survived gastric malignancy and breast cancer, respectively.

On examination (O/E): Five well-circumscribed firm nodules were seen over the right leg with the largest measuring 6 × 5 cm over the anterior leg below the knee and the smallest measuring about 4 cm over the Achilles tendon [Figure 1] and [Figure 2]. One nodule just above the ankle on the anterior aspect showed hemorrhagic crust and purulent discharge and the other over the posterior aspect appeared like a fusion of 2–3 nodules [Figure 3]. The patient had tenderness in all nodules, and areas of pigmentation were noted. There was no palpable inguinal lymphadenopathy.
Figure 1: Well-circumscribed nodules over the anterior aspect of the right leg at the time of presentation

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Figure 2: Evolution of nodules into ulcers over 2 months

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Figure 3: (a) Coalescent nodules above the ankle on the posterior aspect. (b) Exuberant lesion over the anterior aspect of the leg above the ankle (c and d) Nodules below the knee and over Achilles tendon

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Clinically, the differential diagnoses we considered were mycosis fungoides, clear cell acanthoma, dermatofibrosarcoma protruberans, pilomatricoma, and keloidal blastomycosis. Grocott methenamine silver (GMS) staining and smear-KOH for fungus were done, which were negative for fungal elements.

Later, skin biopsy was done from the lesion over the leg and sent for histopathological examination (HPE), which showed hyperkeratotic epidermis with diffuse sheets of atypical lymphocytes, mitotic figures, and epidermotropism [Figure 5]. A section was sent for immunohistochemistry, which showed strong positivity for CD3 and CD45 [Figure 6]. PET-CT abdomen showed multiple enlarged lymph nodes with aortocaval and external iliac being the largest. With all the above clinical findings and lab tests, a diagnosis of cutaneous T-cell lymphoma of T3N2M0 was made.
Figure 4: Resolution of nodules after treatment with six cycles of CHOP-E regimen

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Figure 5: (a) H and E staining, Scanner view (4 ×), slight hyperkeratotic epidermis with diffuse sheets of lymphocytes (b) H and E staining, Low-power view (10 ×) spongiosis, numerous atypical lymphocytes with epidermotropism. (c and d): H and E staining, High power view (40 ×) epidermotropism with atypical lymphocytes in epidermis and dermis

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Figure 6: (a and b) Immunohistochemistry (400 ×): Tumor cells showing CD 3 and CD 45 positive

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The patient was referred to an oncologist where six cycles of intravenous cyclophosphamide, hydroxydaunorubicin, oncovin, prednisone, and etoposide phosphate (CHOP-E) regimen were given followed by five cycles of oral medical chemotherapy of cyclophosphamide, prednisone, and etoposide after which the lesions resolved [Figure 4].

Cutaneous T-cell lymphoma is a serious and rare malignancy of extranodal origin with an annual incidence of about 0.5 per 100,000, affecting more commonly in men.[1] Mycosis fungoides is the most common variant of cutaneous T-cell lymphoma, which is the great mimicker of many conditions clinically and histologically.[2] This case was first diagnosed clinically to be keloidal blastomycosis, a deep fungal infection, because of the presence of keloid-like, nodular lesions.

The main goal of treatment is to relieve the symptoms for remission, and to reduce the progression of the disease. Treatment is based on staging which is divided into the skin- targeted therapies for early-stage disease (1a to 2a) and systemic therapy for advanced stages (2b). Systemic corticosteroids were effective in management. Multiagent chemotherapy with CHOP regimen is very effective for rapid disease control.[3] Other effective modalities include psoralen plus ultraviolet A (PUVA), ultraviolet B (UVB), UVA1, and radiotherapy, electron beam therapy, photodynamic therapy with aminolevulinic acid.[4]

Thus, early diagnosis and prompt treatment help in the resolution of lesions and prevent the spread of the disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Panda S. Mycosis fungoides: Current trends in diagnosis and management. Indian J Dermatol 2007;52:5-20.  Back to cited text no. 1
  [Full text]  
2.
Wobser M, Geissinger E, Rosenwald A, Goebeler M. Mycosis fungoides: A mimicker of benign dermatosis. World J Dermatol 2015;4:135-44.  Back to cited text no. 2
    
3.
Wilcox RA. Cutaneous T-cell lymphoma: 2014 update on diagnosis, risk-stratification, and management. Am J Hematol 2014;89:837-51.  Back to cited text no. 3
    
4.
Bagherani N, Smoller BR. An overview of cutaneous T cell lymphomas. F1000Res 2016;5:1882.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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