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Lymphomatoid granulomatosis of skin: case report A 73-year-old woman developed lymphomatoid granulomatosis (LyG) of skin during treatment with methotrexate, unspecified steroids and sulfasalazine [salazosulfapyridine] for rheumatoid arthritis. The woman with 10 year history of rheumatoid arthritis had been receiving treatment with methotrexate 6 mg/week, unspecified steroids and sulfasalazine [routes not stated; not all dosages stated] along with etodolac, mesalazine and limaprost. However, she developed a small nodule on right upper arm and she also felt a tumour on the right axilla, which eventually increased in size up to 2cm mass after 1.5 months. It was similar to an inflammatory epidermal cyst and the surrounding skin appeared reddish. She was prescribed antibiotics, but after 20 days, the centre of the lesion began to decay. Additionally, a painless normal coloured nodule was also present in the right axilla. Subsequently, a biopsy was performed. Histological studies showed ulceration was covered with necrotic tissue, infiltrating growth of medium-tolarge atypical lymphocytes was noted underneath the ulcerated area. It was accompanied by a small reactive lymphocytes. The atypical lymphocytes infiltrated to the necrotic area and atypical cells showed a tendency to infiltrate the vessels, forming an angiocentric pattern. Cutaneous ulceration was considered secondary to angiocentric infiltration. The dermis demonstrated large area of necrosis. The atypical lymphocytes had irregular medium to large sized nuclei. Immuno-histochemical testing demonstrated that the atypical lymphoid cells were positive for CD 79a, CD 30 and CD 20. Moreover, in-situ hybridisation for EBV showed EBV encoded small RNA expression rate of 70–80%. The clinical investigations were positive for latent membrane protein, but negative for EBV nuclear antigen. Thus, a diagnosis of LyG of skin was made. The woman’s treatment with methotrexate and sulfasalazine was stopped. This resulted in reduced size of the lesion however the necrotic tissue was attached to the surface. Therefore, she underwent debridement leading to even small sized lesion. After 10 weeks of methotrexate discontinuation, the lesion disappeared but the ulcerated scar remained. Author comment: "Iatrogenic lymphoproliferative disorder (LPD) can develop in patients treated with immunosuppressive drugs for autoimmune or other inflammatory diseases. Here, we report a case of lymphomatoid granulomatosis of the skin (LyG) that occurred as a methotrexate (MTX)-associated LPD." Nishida H, et al. A Case of Methotrexate-Associated Lymphoproliferative Disorder (Lymphomatoid Granulomatosis) of the Skin. American Journal of Dermatopathology 41: 448-452, No. 6, Jun 2019. Available from: URL: http:// 803440881 doi.org/10.1097/DAD.0000000000001301 - Japan

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Reactions 21 Dec 2019 No. 1784