A 60-year-old African American female with a history of hypertension presents to the emergency department for an itchy, diffuse rash. She first noticed the lesions a few years prior, and they have progressively become larger and more inflamed. The lesions have become severely pruritic over the last couple of months. Steroid creams did not appear to improve symptoms. Currently, the lesions on her arm have become painful with yellow drainage. The patient denies nausea, vomiting, and fever.
Vitals: Blood pressure 182/90; pulse 100; respiration rate 11; temperature 36.2°C
Constitutional: Alert and oriented, well-nourished, no acute distress
Cardiovascular: Regular rate and rythm
Pulmonary: Lungs clear to auscultation bilaterally
Neck: Supple, no masses or lymphadenopathy
Musculoskeletal: Normal range of motion and strength, no tenderness or swelling
Skin:
- There is diffuse involvement of skin with hypopigmented, dry scaly patches and plaques.
- There is an area of induration in the left axilla measuring 4 x 2 centimeters with purulent discharge.
- Posteriorly, on the buttock, the patient has three focal areas of skin breakdown, consistent with pressure ulcer.
The remainder of the exam is unremarkable.
Complete blood count (CBC) and comprehensive metabolic panel (CMP) were unremarkable.
- Psoriasis
- Eczema
- Nonspecific dermatitis
- Lichenoid dermatoses
- Lupus
- Vitiligo
- Leprosy
- Fungus (histoplasmosis, coccidioidomycosis, etc.)
- Mycosis Fungoides
Mycosis fungoides
A type of cutaneous T-cell lymphoma, is characterized by the proliferation of neoplastic cluster of differentiation 4 (CD4) and T-lymphocytes in the skin. Mycosis fungoides and its leukemic variant, Sézary syndrome, are a rare form of non-Hodgkin’s lymphoma. Patients typically present with a mixture of progressive cutaneous manifestations, such as patches, plaques, tumors, and skin lesions. Both diseases have a poor prognosis in later stages. The first image demonstrates fungating tumors overlying hyperpigmented patches and plaques on the patient’s right arm with areas of purulent discharge concerning for infection.
This patient has experienced a superinfection of her persistent rash, due to underlying mycosis fungoides. Mycosis fungoides has no definite etiology but has been associated with human T-cell virus type 1 (HTLV-1).
In this case, the diagnosis is difficult due to nonspecific skin presentations and a variety of skin disorders that may present similarly [1]. Pathologic examination is required for a definitive diagnosis. Treatment depends on the stage of the lymphoma but includes topical and systemic options. Topical therapies include mechlorethamine (nitrogen mustard), carmustine (BCNU), psoralen plus ultraviolet A (PUVA), ultraviolet B (UVB), and localized skin electron radiotherapy. Systemic therapies include interferon, vorinostat, and chemotherapy [2].
Take-Home Points
- Cutaneous T-cell lymphoma is an uncommon skin disorder that can mimic many benign processes, particularly in its early stages.
- Early identification and referral to dermatology is needed to facilitate diagnosis and management.
- Kelati A, Gallouj S, Tahiri L, et al. Defining the mimics and clinico-histological diagnosis criteria for mycosis fungoides to minimize misdiagnosis. Int J Womens Dermatol. 2017;3(2):100–106. PMID: 28560304
- Al Hothali GI. Review of the treatment of mycosis fungoides and Sézary syndrome: A stage-based approach. Int J Health Sci (Qassim). 2013;7(2):220–239. PMID: 24421750
Author information
The post SAEM Clinical Image Series: The Insidious Rash appeared first on ALiEM.