Sir,
We thank the reader for the interest and putting forward their opinion on our article published in Indian Dermatology Online Journal.[1,2]
Our patient, a 30-year-old female presented to us with nodular erythematous infiltration of the skin [Figure 1a–c] and was diagnosed with acute lymphoblastic leukemia with cutaneous infiltration after thorough work up. The skin biopsy revealed a B-cell type lymphoblastic infiltrate [Figure 2, arrows], and inmunohistochemistry was positive for TdT [Figure 3], PAX-5, CD5, CD3, and negative for CD20 and CD1a. A bone marrow aspirate was performed and showed 80% blast cells with L1 type morphology [Figure 4]. In addition, flow cytometry was positive for CD10, CD13, CD15, and negative for CD20.
Figure 1.
(a) Multiple infiltrated erythematous nodules on the patient's face. (b) Erythematous nodules on the patient's right cheek. (c) The patient's right earlobe with an erythematous infiltrated aspect
Figure 2.
Skin biopsy stained with H and E, ×10. Periadnexal and deep dermal B-cell type lymphoblastic infiltrate
Figure 3.
Skin biopsy, TdT immunofluorescence, ×10. Diffuse and strong, finely granular pattern, uniformly distributed in the nucleus
Figure 4.
Bone marrow aspirate. Hypercellular bone marrow, with decreased megakaryocytes and replaced with 90% lymphoblasts
The patient was then referred to the hematologist and was treated with systemic chemotherapy (remission–induction, consolidation and maintenance) consisting of vinca alkaloids, anthracyclines, and corticosteroids. She presented complete clearance of the cutaneous lesions after a 6-month follow-up [Figure 5]. We did not include the details of the bone marrow aspirate in our article as it may take away the suspense of the quiz as suggested by the reviewers and editors.
Figure 5.
The patient's right cheek and earlobe 6 months after starting chemotherapy
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
REFERENCES
- 1.García-Meléndez ME, Eichelmann K, Vázquez-Martínez OT, Ocampo-Candiani J. SkIndia Quiz 18: Multiple erythematous nodules in a 30-year-old woman. Indian Dermatol Online J. 2015;6:228–9. doi: 10.4103/2229-5178.153033. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Gupta S, D’souza P, Dhali TK. Multiple erythematous nodules in a 30-year-old woman. Indian Dermatol Online J. 2016;7 doi: 10.4103/2229-5178.178095. ahead of Print. [DOI] [PMC free article] [PubMed] [Google Scholar]