An unusual presentation of a case of T cell angiotropic (intravascular) lymphoma

Primary effusion lymphoma presenting as a cutaneous intravascular lymphoma

Primary effusion lymphoma (PEL) is a rare and aggressive lymphoma that arises in the context of immunosuppression and is characterized by co-infection with Epstein-Barr virus (EBV) and human herpesvirus-8/Kaposi sarcoma-associated herpesvirus (HHV-8/KSHV). It was originally described as arising in body cavity effusions, but presentation as a mass lesion (extracavitary PEL) is now recognized. Here, we describe a case of PEL with an initial presentation as an intravascular lymphoma with associated skin lesions. The patient was a 53-year-old man with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) who presented with fevers, weight loss and skin lesions concerning for Kaposi sarcoma (KS). A skin biopsy revealed no evidence of KS; however, dermal vessels contained large atypical cells that expressed CD31 and plasma cell markers but lacked most B- and T-cell antigens. The atypical cells expressed EBV and HHV-8. The patient subsequently developed a malignant pleural effusion containing the same neoplastic cell population. The findings in this case highlight the potential for unusual intravascular presentations of PEL in the skin as well as the importance of pursuing microscopic diagnosis of skin lesions in immunosuppressed patients.

[Intravascular lymphoma: two case reports demonstrating the heterogeneity of the disease]

Intravascular lymphoma (IVL) is a rare subtype of extranodal large-B-cell lymphoma, histologically characterized by accumulation of clonal lymphocytes in small vessels of different organs. Overall survival is usually poor. The clinical manifestations are highly variable, depending on the involved organs. Cutaneous and neurological involvement is frequent; the cutaneous symptoms are heterogeneous with erythema, erythematous papules and plaques, generalized telangiectases and lesions resembling panniculitis or Kaposi sarcoma. IVL may also be limited to the skin; this entity is included the current classifications. We present here two patients with two different variants of IVL. One showed only skin involvement with panniculitis-like induration and responded well to therapy with Rituximab-CHOP (Rituximab plus Cyclophosphamide, Doxorubicin, Vincristine, Prednisolone). The other patient had distinctive cutaneous and neurological symptoms which did not respond to therapy. By means of these two patients, we present the heterogeneity of IVL and discuss current aspects of diagnosis and treatment.

Skin manifestations of intravascular lymphoma mimic inflammatory diseases of the skin

BACKGROUND

Intravascular lymphoma (IVL) is fatal when it is diagnosed late in the course. Sometimes skin lesions enable early diagnosis, but criteria for diagnosis are not well established.

OBJECTIVES

To demonstrate the clinical spectrum of skin lesions of IVL and to correlate it with clinical outcome; to identify features differentiating between B-cell and T-cell IVL with skin involvement.

METHODS

Review of 97 articles reporting on total of 224 patients with IVL.

RESULTS

Skin lesions were mentioned in 90 of 224 patients. They were nodules and/or plaques (49%) or macules (22.5%) of red (31%) or blue to livid (19%) colour on the leg (35%), the thigh (41%) and the trunk (31%). Telangiectases were present in only 20% of the patients. Oedema (27.5%) of the legs and pain (24%) were often accompanying. No criteria enabled distinction between lesions restricted to the skin and skin lesions concurrent with IVL in other organs, but when the disease was restricted to the skin, the prognosis was favourable (10% vs. 85% fatal outcome). Skin lesions of T-cell IVL are indistinguishable from those of B-cell IVL.

CONCLUSIONS

Forty per cent of all patients with IVL have skin lesions, these being red, sometimes painful plaques located typically on the lower extremities, accompanied by oedema. A clinician risks misinterpreting these changes as thrombophlebitis, erythema nodosum or erysipelas. Neither clinical course nor differentiation of the lymphoma can be predicted from the morphology of skin lesions, but involvement of other organs at the time of diagnosis indicates a poor prognosis.

A new approach to the diagnosis and treatment of intravascular lymphoma

In intravascular lymphoma (IVL) tumor cells are initially restricted to vascular lumina. Neurological syndromes predominate and are caused by ischemia as well as tumor infiltration into the nervous system. Ante mortem diagnosis is challenging and frequently impossible. Chemotherapy is effective if started prior to ischemic damage. Over a three year period, we have diagnosed IVL in seven patients. Tissue diagnosis could be accomplished in only three cases. Forthose in whom tissue diagnosis failed we based our diagnosis on clinical presentation, typical magnetic resonance imaging findings, spinal fluid cytopathology, and molecular analyses. Six patients were treated with methotrexate chemotherapy alone or in combination with CHOP. Three patients are in complete remission 9-20 months after initial diagnosis. Another patient achieved a partial response. Two patients died due to progressive disease shortly after initiation of treatment. Grade III toxicity was observed in only 4 of 61 cycles. Based on a small retrospective series of patients, we conclude that methotrexate is a well tolerated and effective agent for the treatment of IVL.