Since my early training in Dermatopathology I used to love esinophils! Their characteristic esinophilic granules give them this typical elegant red color making them look so beautiful under the microscope especially when they are conspicuous in the tissue.

Conspicuous esinophils are encountered in many dermatologic conditions that include vesiculobullous disorders, disorders of blood vessels, infections and infestations in addition to many miscellaneous conditions and several tumors such as: Langerhan’s cell histiocytosis, tumor like esinophilic granuloma, juvenile xanthogranuloma, SCC and KA.

However, the presence of conspicuous amounts of these beautifully looking cells among a superficial and deep lymphohistiocytic infiltrate in biopsies taken from lesions that are clinically rather non specific may point to a possible underlying hematologic malignancy, what we describe as esinophilic dermatosis of hematologic malignancy. In such condition, patients present with non specific pruritic papules, nodules or vesiculobullous lesions refractory to standard treatment. Usually the eruption develops concomitantly with or within months to years after the diagnosis of a hematologic malignancy mainly CLL. It is of great importance to know that sometimes, development of these lesions may precede the diagnosis of the hematologic malignancy making the establishment of a final diagnosis perplexing! Clinically and histopathologically, one might think of insect bite reaction in such lesions, but patients usually deny any arthropod assaults.

What I want to say here is that one should consider this entity in dealing with esinophil rich non specific eruptions in patients with hematologic malignancy with no history of arthropod bites and we should not forget that the malignancy is not necessarily evident at the time of onset of the rash. These elegant cells might be the only clue of an upcoming monster!!