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Building Blocks of Dermatopathology

BAD DermpathPRO Learning Hub: Diagnostic Clues

Diagnostic Challenge
Interesting Case

Case Number : CT0024 Dr. Richard Carr

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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M50. Known CLL. Presented with a polymorphic rash (papular, macular and vesicular) on limbs. Initially thought to be a drug reaction. All chemotherapy stopped but rash persisted. Case c/o Dr Arti Bakshi

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Dr. Mona Abdel-Halim - First thought: exaggerated insect bite reaction in the setting of a CLL based on depth of infiltrate with subcutaneous fat involvement and lots of esinophils. Another suggestion to be verified by DIF is paraneoplastic polymorphic pemphigoid. Also IHC for CD20, CD5, CD43 and CD23 should be done to verify the presence of leukemic cells in the infiltrate as cells of CLL can infiltrate sites of skin inflammation. Edited October 16, 2015 by Guest
Guest - My first thought, given the vesicles and eosinophils, is vesicular pemphigoid, which has been reported with CLL.
IgorSC - I believe this is a case of Insect bite-like reaction based on histology and the clinical history of hematological disease, particularly CLL. Nice case!

Dr. Richard Carr - I have asked Arti to feedback on this rather lovely case, probably on Monday.

Guest Romualdo - Agree with insect bite-like reaction (bullous pemphigoid-like disease) associated with CLL. According to the literature there is no association with insect bites in most of the cases described.
Arti Bakshi - Great responses! Yes, this a case of 'exaggerated insect bite like reaction in CLL, the preferred terminology now being 'Eosinophilic Dermatosis of Haematological Malignancies' as this reaction can occur in hematologic conditions other than CLL. Also, as Romualdo rightly pointed out, patients often deny any history of insect bites (and rash can occur on non exposed sites as well). The diagnosis does require exclusion of other causes of an eosinophil rich infiltrate such as infections, parasitic infestations and IMF for bullous pemphigoid (all of which was done in this case). Immunohistochemistry was done to exclude an infiltrate of CLL and this was negative too.

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