Large CD30- Positive Cells In Cutaneous Benign Lymphoid Infiltrate

摘要

We are reporting a clinical presentation for a case that resamples CD30 positive lymphoproliferative disorder. The clinical challenge, the deferential diagnosis and review of literature have been discussed. Clinical Course This is the case of a 44 year old single smoker male with past medical history of duodenal ulcer, benign prostatic hyperplasia, diabetes mellitus, hyperlipidemia and hypertension. The patient presented to the hospital for evaluation of a 6 year history of multiple non pruritic red nodulo-plaque lesions on the head and neck regions without lymphodenpathy or any other systemic symptoms or signs (figure 1). One year before presentation patient had undergone “isotretinoin” therapy for 6 months for a clinical diagnosis of “ Granulomatous Rosacea” without any benefit. Laboratory work up revealed normal cell blood count, normal electrolytes, normal urine analysis, negative anti-nuclear antibody (ANA), HBsAg and HCV none reactive. The patient was started on the following medications; glyburide, metformine, doxazosin and amlodipine about two years after the onset of the above complaint. The first clinical impression was set for Jessner lymphocytic infiltrate with differential diagnosis of lupus erythematosus and cutaneous sarcoidosis.The first skin lesion biopsy from the temporal area revealed normal epidermal histological features with dense perivascular and periadnexal lymphocytic infiltrate in the dermis. No epitheloid granuloma identified, and the findings most likely suggestive of Jessner lymphocytic infiltrate, and less likely to be lupus erythematosus.Hence, the patient was treated with antimalarial drugs (hydroxychloroquine) 200 mg/day for 5 months but without improvement. A second biopsy was performed later on from neck area and showed unremarkable epidermis with dense dermal perivascular and periadnexal lymphocytic infiltration that has a nodular appearance with occasional diffuse expansion within the dermis, it is composed mainly of small to medium sized lymphocytes admixed with histiocytes, smaller number of large lymphocytes, many eosinophils and rare plasma cells, the small lymphoid cells frequently show cleaved or irregular nuclear membrane. Mitotic figures are occasionally seen, and prominent vascular channels in many areas with plump endothelial cells identified (Figure 3 A, B).Immunohistochemistry staining was performed and the large cells expressed CD3, CD30 and CD45 (Figure 3. C, D). And were negative for CD20, Alk, EBV (figure 3.E, F) and EMA. The proliferative index by Ki-67 labeling is 20%. Therefore, the findings were in keeping with the diagnosis of CD30 positive T – cell lymphoproliferative disorder. The patient was treated with prednisolone (40 mg/ day) for one week, reduced gradually to (5 mg/day). Methotrexate (25 mg /week) for 6 months and after treatment, lesions mildly have improved and decreased in size but fully recovery had not been accomplished and they relapsed in two months after ceasing methotrexate (figure 2).Further molecular testing for T cell rearrangement was performed on paraffin embedded tissue and no monoclonality was detected.