A 36-year-old male with a 1-month history of a flat, erythematous scalp lesion on the left temple

    Rachel Fayne, a 3rd year medical student, Miller School of Medicine, Univ of Miami, is presenting this case report.


    Clinical History

     The patient is a 36-year-old male with a 1-month history of a flat, erythematous scalp lesion on the left temple. Due to the month-long persistence of the rash, the patient underwent evaluation where a skin biopsy was performed. The patient was largely asymptomatic with no enlarging lymph nodes, unexpected weight loss, fevers, chills or night sweats. The patient’s past medical history is significant for diabetes mellitus and alpha-1-antitrypsin deficiency, for which he has not experienced any symptoms or indications of organ failure.

    Histologic Findings

    Histological sections displayed pandermic nodular atypical lymphocytic infiltrates forming expanded, irregular germinal centers. Grenz zone was noted and the adnexal structures were spared. The sections showed a large number of centroblasts and fewer centrocytes (grade 3) with frequent plasma cells admixed, some of which were found within tumor nodules.

    Immunohistochemistry showed the lymphoma cells were positive for CD20, BCL-6 and CD10 and negative for CD3 and BCL2. CD21 showed a scattered, expanded, irregular follicular dendritic network. Kappa and lambda light chain in situ hybridization showed monotypic expression of kappa light chain in the plasma cells. These plasma cells are considered as unusual plasma cell differentiation of neoplastic B cells. The lack of BCL2 expression favors a primary cutaneous origin. However, clinical staging is required to confirm the diagnosis.

    Molecular studies were positive for clonal IgH gene rearrangement and negative for T-cell receptor gene rearrangement, indicating a clonal B-cell lymphoproliferative disorder.

     

    Diagnosis

    Primary Cutaneous Follicular Center Lymphoma

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    Conference: