Cutaneous marginal zone lymphoma following anthrax vaccination
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LETTER TO THE EDITOR
Cutaneous marginal zone lymphoma following anthrax vaccination Jocelyn B. Chandler 1,2
&
Reid Waldman 3 & Steven B. Sloan 3 & Michal G. Rose 1,2 & Ellice Y. Wong 1,2
Received: 6 October 2020 / Accepted: 2 November 2020 # This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2020
Dear Editor, A 38-year-old male veteran was referred to dermatology for a 1-cm tender pink nodule on his upper arm at the site of an anthrax vaccination administered 14 months prior. He reported that the nodule was preceded by “swelling the size of a baseball” at the anthrax vaccine injection site that developed after receiving the fifth dose of the vaccine series. He did not have a sustained reaction to the previous injections. The patient denied systemic symptoms including fever, weight loss, night sweats, or lymphadenopathy. His past medical and family history were unremarkable. Due to persistence of the lesion, a skin biopsy was performed followed by excision. Histopathology revealed an unremarkable epidermis with a dense dermal lymphoid infiltrate without germinal center formation, predominantly composed of small to medium sized lymphocytes with abundant plasma cells that were perivascular, perifollicular and periadnexal in distribution (Fig. 1a, b, X100 and X400, respectively). A CD3 immunostain highlighted a dense T cell infiltrate (not pictured), while CD20 highlighted B cells in a nodular distribution (Fig. 1c, X200). A CD138 immunostain highlighted numerous plasma cells, predominantly present at the periphery of the lymphoid infiltrate (Fig. 1d, X200) that were monoclonal with kappa-restriction by kappa and lambda immunostains (Fig. 1e, f, X200). Peripheral blood counts were within normal limits and peripheral blood flow cytometry did not reveal any circulating lymphoma cells. In
addition, CT chest/abdomen/pelvis did not reveal lymphadenopathy. Overall findings were consistent with a cutaneous low-grade marginal zone lymphoma. Solitary primary cutaneous marginal zone lymphomas are generally treated with local radiation therapy and/or excision. In this patient’s case, definitive excision was performed and radiation therapy was reserved in case of recurrence. The patient is currently asymptomatic and doing well. Cutaneous marginal zone lymphomas occurring at the site of influenza and hepatitis vaccinations have been described [1–7]. However, to our knowledge, this is the first case report of a lymphoma developing at the site of an anthrax vaccination. The anthrax vaccine contains an attenuated strain of B. anthracis and is adsorbed to aluminum hydroxide. It is usually well tolerated. Previous reports have identified the vaccine’s adjuvant, aluminum hydroxide, as the cause of pseudolymphoma when administered as a component of the hepatitis A and B vaccines [3]. While cutaneous pseudolymphoma was considered in this case, the presence of kappa-restricted plasma cells indicated a monoclonal proliferation consistent with extranodal marginal zone ly
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