Unusual cutaneous manifestations of B-cell chronic lymphocytic leukemia

An Unusual FDG-PET/CT Documentation in Aleukemic Leukemia Cutis: Atypical Penile, Scrotal, and Leg Muscles Involvement

Aleukemic leukemia cutis (ALC) is a rare condition with a relatively poor prognosis, clinically presenting as skin and subcutaneous nodules commonly involving head and neck region with discrete atypical leukemic cells infiltrating in the skin on histopathology. The lesions on the genital area skin are seldom reported. A 49-year-old male presented with joint pains and multiple subcutaneous nodules clinically with biopsy proving it as leukemia cutis. Bone marrow aspiration and biopsy were suggestive of normocellular myeloid preponderant bone marrow with mild increase in eosinophils. The ¹⁸ F-fluorodeoxyglucose positron emission tomography/computed tomography ( ¹⁸ F-FDG PET/CT) revealed metabolically active FDG avid ill-defined soft tissue attenuation involving the entire length of penile shaft with central necrotic area, diffuse scrota skin thickening, and lateral compartment muscles of left leg, in addition to multiple hypermetabolic metastatic lymph nodes, and diffuse hypermetabolic marrow in humerii and femora. Despite prompt investigations and initiation of management, the patient succumbed in 15 days post-FDG PET/CT. The present report depicts an atypical case of ALC, with FDG PET-CT showing extensive and unusual sites of disease involvement, emphasizing its potential role in ALC.

Leukemia Cutis as an Early Presentation or Relapsing Manifestation of Chronic Lymphocytic Leukemia (CLL)

Background and Objective:

Cutaneous infiltration by Chronic Lymphocytic Leukemia (CLL) is a rare complication. The clinical presentation, impact of it on disease prognosis, and the proper treatment choice are not clear. Here in our review, we try to answer these questions.

Acquisition of evidences:

A systematic search of PubMed, and Google Scholar for English language articles published from Jan 2000 to June 2019.

Synthesis of evidences:

A total of 56 cases were identified, with a median age of 66 years. Of these cases 43 were males and 12 were females, and one missing data, with a ratio of 3,6:1. Head and neck were most commonly involved. The commonest clinical presentation was papulonodular lesions, and the majority were diagnosed at an early stage. CLL skin involvement at the site of old herpetic lesions was common. Because of the rarity of the disease, treatment modalities varied widely, and there are no consensus on treatment. The majority were treated with chemotherapy. In general, 35 (77.8% - of the non-missing data) patients responded to treatment (25 patients had a complete remission and 10 a partial remission). All patients ≤60 years had an early-stage disease, on the other hand, all patients with advanced-stage were >60 years.

Conclusion:

Patients with early-stage and localized leukemia cutis can benefit from observation alone strategy, while intervention in young patients with advanced disease is warranted. Skin infiltration by CLL does not affect prognosis, as most patients attained complete or partial remission with a very low progression rate.

Chronic lymphocytic leukemia and the skin: implications for the dermatologist

B-cell chronic lymphocytic leukemia (CLL) is the most prevalent leukemia in the United States, and its diagnosis can have many dermatologic implications. For one, the cutaneous manifestations of CLL include several entities, most notably leukemia cutis, eosinophilic dermatosis of hematologic malignancy, and a heightened risk of skin infections. Additionally, CLL patients are at an increased risk of secondary malignancies, most commonly of the skin. Furthermore, a number of commonly utilized treatments for CLL have cutaneous implications which should be considered in the interdisciplinary management of CLL patients. In this review, we will provide an update on the diverse cutaneous manifestations of CLL and CLL-directed therapies in order to help guide dermatologic management of this increasingly prevalent patient population.

Eosinophilic folliculitis, eosinophilic dermatosis of hematologic malignancy and acneiform follicular mucinosis: Two case reports and a review of the literature highlighting the spectrum of histopathology

Within the literature, there is overlap in the histopathological features described in eosinophilic folliculitis associated with chronic lymphocytic leukemia (CLL), eosinophilic dermatosis of hematologic malignancy, and acneiform follicular mucinosis. These disorders are described with varying degrees of superficial and deep lymphocytic and eosinophilic inflammation demonstrating perivascular, perifollicular, and folliculocentric involvement with or without follicular mucin deposition. Given significant histopathological overlap, these diagnoses may represent a continuum on a spectrum of dermatoses. Here, we present two cases with histopathological elements that reflect components of this clinicopathological spectrum and compare our findings with previously reported cases to compare and contrast reported features. Our first case is a 71-year-old African American man with long-standing CLL who developed a pruritic erythematous papular eruption on the face and chest with biopsy revealing a dense folliculotropic lymphocytic infiltrate with conspicuous eosinophils and follicular mucinosis. Our second case is a 70-year-old Caucasian man recently diagnosed with CLL/small lymphocytic lymphoma who developed an erythematous papular rash on the neck and face with biopsy revealing superficial and deep perivascular and periadnexal lymphocytic inflammation with scattered eosinophils. Characterization of our two cases and comparison with available literature suggest that these disorders may represent a continuum of dermatoses.

Cutaneous manifestation of leukaemia on the penis-the possible implications

Skin lesions are common in the patients with chronic lymphoid leukaemia (CLL); however, leukaemia cutis is a cutaneous manifestation secondary to any form of leukaemia and generally an uncommon phenomenon. They typically present on the face and neck as well as exposed areas. Our case looks at a 78-year-old gentleman with known CLL who presented with an asymptomatic raised lesion in his inner prepuce. The lesion was excised and his immunohistology staining confirms expression of CD5, CD20 and CD23 that is consistent with cutaneous manifestation of CLL. This case highlights the importance of taking leukaemia cutis into consideration in patients with known CLL with unusual features.

[A Listeria breast abscess in a man]

INTRODUCTION

Listeriosis is a food-borne illness leading to bacteriemia or central nervous system infection especially in pregnant women or high-risk patients. It is rarely a localized infection. Breast contamination has rarely been reported in lactating women. We report a breast abscess in man.

CASE REPORT

A 80 year old man, hypertensive and arrhythmic, was explored for weakness and dehydration. Type 2 diabetes and chronic lymphocytic leukemia were diagnosed. Clinical examination disclosed a breast abcess related to L monocytogenes infection. Histopathological study also revealed a breast subcutaneous infiltration by chronic lymphocytic leukemia.

CONCLUSION

Listeriosis sometimes uncover an unknown immunosuppression, especially in the elderly. Breast is a non-sterile tissue containing a stable microbiome partly from digestive origin. It can thereby be contaminated by Listeria. The specific cutaneous infiltrate of chronic lymphocytic leukemia can create the conditions for a local infection.

Lymphocytoma cutis on the inguinal region: report of a rare case of benign lymphoproliferative disorder

Lymphocytoma cutis, or benign reactive lymphoid hyperplasia, is an inflammatory skin lesion that mimics clinically and histologically malignant lymphoma. Most cases are idiopathic, but they may also be triggered by multiple factors, such as insect bites, tattoos, injections and herpes zoster. Clinically, the lesions are erythematous, soft papules, plaques or nodules, usually located on the upper limbs and face. The diagnosis is mainly based on histopathology and immunohistochemistry. Corticosteroid injections, cryosurgery, PUVA therapy, radiotherapy and surgery can be therapeutic options in cases requiring immediate treatment. To demonstrate an atypical presentation of this tumor, a case lymphocytoma skin on the groin will be reported, describing its diagnosis and treatment.

Bullous leukemia cutis mimicking facial cellulitis

Bullous leukemia cutis is an uncommon clinical manifestation of cutaneous infiltration by leukemic cells, from B-cell chronic lymphocytic leukemia. We present the case of a 67-year-old, female, chronic lymphocytic leukemia patient. She was taking chlorambucil and developed facial edema with erythema and warmth, misjudged as facial cellulitis. Two days later, she developed bullous lesions in the arms, legs, neck and face. The histopathology of facial and bullous lesions confirmed leukemia cutis. All lesions disappeared following the administration of rituximab combined with cycles of fludarabine and cyclophosphamide. Although soft tissue infections are common complications in patients undergoing chemotherapy, leukemia cutis can also resemble cellulitis.

CLL/SLL with initial presentation as a longstanding cutaneous plaque: a rare case

While chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is the most common leukemia in the western world, it uncommonly initially presents as a cutaneous lesion. When it does, it is often found incidentally in the context of another distinct lesion. We present a case of CLL/SLL that initially presented as a solitary nodular erythematous plaque on the left flank of a healthy 60-year-old man without lymphadenopathy or constitutional symptoms. The lesion had been present for many years, but had recently begun to grow and become pruritic and painful. Excisional biopsy revealed a large nodular aggregate of variably sized CD20(dim), CD5(+), CD23(+), BCL-2(+) atypical lymphocytes in the dermis without epidermotropism. The lymphocytes were negative for BCL-1/cyclinD1, BCL-6, and CD10, and no other background lesion was identified. This constellation of biopsy findings was consistent with CLL/SLL. This case emphasizes the potential for involvement by CLL/SLL in the cutaneous biopsies of otherwise asymptomatic patients.

Cutaneous primary B-cell lymphomas: from diagnosis to treatment

Primary cutaneous B-cell lymphomas are a heterogeneous group of mature B-cells neoplasms with tropism for the skin, whose biology and clinical course differ significantly from the equivalent nodal lymphomas. The most indolent forms comprise the primary cutaneous marginal zone and follicle center B-cell lymphomas that despite the excellent prognosis have cutaneous recurrences very commonly. The most aggressive forms include the primary cutaneous large B-cell lymphomas, consisting in two major groups: the leg type, with poor prognosis, and others, the latter representing a heterogeneous group of lymphomas from which specific entities are supposed to be individualized over time, such as intravascular large B-cell lymphomas. Treatment may include surgical excision, radiotherapy, antibiotics, corticosteroids, interferon, monoclonal antibodies and chemotherapy, depending on the type of lymphoma and on the type and location of the skin lesions. In subtypes with good prognosis is contraindicated overtreatment and in those associated with a worse prognosis the recommended therapy relies on CHOP-like regimens associated with rituximab, assisted or not with local radiotherapy. We review the primary cutaneous B-cell lymphomas, remembering the diagnostic criteria, differential diagnosis, classification, and prognostic factors and presenting the available therapies.

Small lymphocytic lymphoma with florid perniosis-like features: a case report

BACKGROUND

Small lymphocytic lymphoma is a relatively rare B-cell non-Hodgkin lymphoma that is considered to be the tissue equivalent of the much more common entity chronic lymphocytic leukemia. Cutaneous manifestations of small lymphocytic lymphoma are infrequent and the literature regarding them sparse. We describe here a case of a patient with a history of small lymphocytic lymphoma who developed perniosis-like features of the digits.

CASE PRESENTATION

An 86-year old male patient with previously diagnosed small lymphocytic lymphoma developed painful erythematous swelling of the periungual area of his fingers and toes. This was associated with a dense dermal infiltration of CD5-positive B-lymphoid cells consistent with his low-grade B-cell lymphoma. Although partially refractory to local radiotherapy, the painful swelling of the fingers and toes resolved fully following systemic therapy with chlorambucil and rituximab.

CONCLUSIONS

This unusual cutaneous manifestation of a lymphoma and the favourable response to systemic therapy may be instructive for the management of other patients who develop similar perniosis-like features.

A unique case of concurrent chronic lymphocytic leukemia/small lymphocytic lymphoma and lymphomatoid papulosis in the same biopsy

Chronic lymphocytic leukemia (CLL/SLL) is the most common leukemia in the western world and its cutaneous dissemination a very uncommon phenomenon. Lymphomatoid papulosis (LyP) is a CD30+ lymphoproliferative disorder characterized by chronic, recurrent and self healing skin lesions. Up to 20% of patients with LyP have a coexistent lymphoma. While the association between the two entities has been reported, their coexistence has never been documented. We describe a 74-year-old man with known CLL and thrombocytopenia who presented with a 2 year history of recurrent nodules and plaques to both arms and legs that resolved within 4-6 weeks after administration of rituximab and bendamustin for his CLL treatment. His biopsies showed an atypical lymphoid infiltrate, composed of large and pleomorphic cells with a nodular and interstitial pattern in a background of eosinophils. Immunohistochemical staining revealed a pattern of two separate yet coexisting neoplastic processes; a large CD30 positive T-cell lymphoproliferative disorder, while the other one was diagnostic of a neoplastic B-cell process (leukemia cutis). A diagnosis of coexistent LyP and cutaneous involvement by CLL/SLL was rendered. The simultaneous presence of both disorders can be a pitfall in the differential diagnosis of large cell lymphomas, such as Richter's transformation of CLL/SLL.

Extramedullary chronic lymphocytic leukemia: systematic analysis of cases reported between 1975 and 2012

The prognostic significance of extra-medullary chronic lymphocytic leukemia (EM-CLL) is unknown. We conducted a Medline database systematic search analyzing English language articles published between 1975 and 2012 identifying 192 cases. Patients with EM-CLL were more commonly treated than not (p < .001). Skin and central nervous system (CNS) were the most commonly reported sites of organ involvement. Survival after diagnosis of EM-CLL appeared to depend on the site of EM involvement. Prospective evaluation and further studies of EM-CLL are warranted.

Leukaemia cutis in chronic lymphocytic leukaemia following varicella zoster virus reactivation

We report a case of a 75-year-old male with indolent chronic lymphocytic leukaemia (CLL) for 8 years, who presented with a 6-month history of a painful, zosteriform eruption in a T3-4 distribution that evolved into an unusual crop of papular nodules. Upon biopsy and immunostaining of these lesions CLL was proven consistent with leukaemia cutis related to varicella-zoster virus reactivation. In the absence of other treatment indices, he was commenced on chlorambucil with successful resolution of both his pain and the lesions.

Cutaneous presentation of chronic lymphocytic leukemia as unique extramedullar involvement in a patient with normal peripheral blood lymphocyte count (monoclonal B-cell lymphocytosis)

Skin infiltration by chronic lymphocytic leukemia (CLL) is very rare and almost all reported cases occur in advanced stage. We report a patient with no relevant past medical history who presented with cutaneous erythematous plaques. A punch biopsy showed typical CLL morphologic and immunophenotypic features. Subsequent studies revealed a normal lymphocyte count in peripheral blood, and there was no evidence of lymphadenopathy or organomegaly. Flow cytometry demonstrated a clonal B-cell population both in the bone marrow and peripheral blood (1.60 × 10(9)/l) with a CLL phenotype, but it did not fulfill required criteria for CLL diagnosis. Without cutaneous involvement, this case should be classified as monoclonal B-cell lymphocytosis.

An urologic face of chronic lymphocytic leukemia: sequential prostatic and penis localization

We report a patient with chronic lymphocytic leukemia (CLL) in whom a leukemic involvement of prostate and penis occurred in the advanced phase of his disease. Obstructive urinary symptoms were indicative of prostatic CLL infiltration, followed by the occurrence of an ulcerative lesion on the glans. Histologic examination confirmed the neoplastic B-cell infiltration. Both localizations responded to conventional treatments. A review of the literature confirms that leukemic involvement of the genito-urinary system is uncommon in CLL patients. However, it should be considered in CLL patients with urologic symptoms and a long history of the disease.

Granuloma annulare-like eruption associated with B-cell chronic lymphocytic leukemia

BACKGROUND

Cutaneous granulomatous inflammation can occur in patients with T-cell lymphoma and Hodgkin disease. We describe the unusual microscopic pattern of a granuloma annulare (GA)-like eruption co-existing with B-cell chronic lymphocytic leukemia (B-CLL).

METHODS

We reviewed the histopathology and immunophenotype of skin biopsies from two patients with B-CLL and cutaneous lesions resembling GA.

RESULTS

Both patients had symptomatic cutaneous lesions clinically resembling GA; one had lesions refractory to standard dermatologic therapy. Histopathology showed GA-like palisaded histiocytic infiltration, with subtle collections of lymphocytes interspersed among the granulomatous inflammation. Immunohistochemistry showed strong expression of CD20 and CD79a, with aberrant CD5 co-expression, confirming cutaneous involvement by B-CLL.

CONCLUSIONS

Co-existence of a GA-like infiltrate and cutaneous B-CLL raises the possibility that granulomatous inflammation occurs as a secondary response to dermal infiltration by leukemic cells. Because histopathologic findings can be subtle, knowledge of this association is essential to avoid overlooking the diagnosis. Regardless of whether histopathology reflects a reactive or primary phenomenon, documentation of cutaneous involvement by B-CLL may serve as a rationale for specific treatment of the underlying B-CLL in patients with skin lesions unresponsive to dermatologic therapy and for whom there is no other justification for leukemia-targeted therapy.

Plasmablastic lymphoma involving the penis: a previously unreported location of a case with aberrant CD3 expression

Lymphomas of the penis are rare and can either arise at this site or be a manifestation of systemic disease. We report the case of an elderly man with a plasmablastic lymphoma (PBL) involving the uncircumcised penile prepuce. The neoplasm was composed of plasmablasts positive for monotypic immunoglobulin lambda light chain, CD3, CD79a, CD138 and Epstein-Barr virus encoded RNA (EBER), and was negative for CD2, CD5, CD7, CD20, and PAX5. This case is highly unusual for at least two reasons. The penile foreskin is a rare location for lymphoma and PBL at this site has not been reported. Secondly, the tumour was shown by immunohistochemistry to be positive for the T-cell marker CD3. Lineage ambiguity in terminally differentiated B-cell lymphomas has been reported to be closely related with immune compromise and is associated with Epstein-Barr virus infection. The literature on penile lymphomas is also reviewed.