Cutaneous T-cell lymphoma presenting as disseminated, pigmented, purpura-like eruption

A 48-year-old man with a history of psoriasis, who had received no oral pharmacologic treatment, presented in March 2000 with a progressive, cutaneous, pruritic eruption that began on his arms and legs, and became generalized. Examination revealed discrete, purpuric elements disseminated over the entire cutaneous surface, and in some areas confluent, large, erythematous, purpuric patches (1, 2). The palmoplantar surfaces and mucous membranes were spared. No lesions suggesting parapsoriasis or the usual presentation of cutaneous T-cell lymphoma (CTCL) were present. Figure 1Open in figure viewerPowerPoint Confluent, large, erythematopurpuric patches with sharply pointed purpuric elements on the buttocks Figure 2Open in figure viewerPowerPoint Similar lesions on the lower limbs Histopathologic examination of a cutaneous specimen showed numerous atypical lymphocytes in the superficial dermis, slight changes at the dermo-epidermal junction, and an intense epidermotrophism, with atypical lymphocytes in the epidermis. These intraepidermal atypical lymphocytes were present both isolated and forming aggregates of 4-7 cells (Fig. 3). Immunohistochemical studies demonstrated that these lymphocytes were T-helper cells. Figure 3Open in figure viewerPowerPoint Atypical lymphocytes in the superficial dermis, slight changes at the dermo-epidermal junction, and intense epidermotrophism, with atypical lymphocytes. Intraepidermal lymphocytes were present both isolated and forming small cellular aggregates Routine laboratory tests were normal, except for slight hypercholesterolemia. Direct examination of peripheral blood, coagulation, antinuclear antibody (ANA) immunofluorescent test, body scanner, and bone marrow study were normal. CTCL stage IB was diagnosed and psoralen plus UVA (PUVA) therapy was initiated.