Case Number : Case 1524 - 27 April Posted By: Guest

PPD-like MF?

The first 4 images and the next four as well are very PPD like. However, there is definite lymphocyte atypia in the second set, but rather focal tagging. CD4s>>CD8s. Agree with Raul, purpuric Mycosis fungoides. Was the patient applying steroids?

Difficult case...I don't see any definite lymphocyte atypia, not even a convincing junctional lymphocytic spreading, but i agree that a PPD-like MF fits clinically perfectly. I can't wait to know the diagnosis.

Yes, Vincenzo, this is a difficult one. Cant say that I have a firm diagnosis either and I put it in more for discussion's sake. 

Purpuric MF was my concern too, but clinically the rash comes and goes and can settle spontaneously without steroids. The biopsies were done in 2013/14 and at the last clinic a couple of weeks ago, his rash had not progressed at all (has not been on any treatment for some time). The CD4:CD8 ratio is skewed, but this can occur in many inflammatory states too. TCRPCR did not show clonality.

Given the distribution of lesions, any other suggestions? (will leave the case for another day)

As nitin suggested, the other diagnosis that could fit  is sdrife or baboon syndrome but recurring and for many years? i cannot make this fit. I was considering atypical case of PPD or maybe itching púrpura that can be recurring and affect the folds but is difficult to assure 100% the diagnosis.

Yes, I know. Thought that the vascular injury is secondary to a drug, although the rest of histology associated with SDRIFE is not present. Could this be some kind of contact dermatitis??? Not a great deal of spongiosis though. 

Thanks for all your comments. As I said, there is no firm bottom line here but I think you all have covered the entire d/d pretty well!

Babboon syndrome or SDRIFE did fit well with the clinical description and distribution of rash, but there was no relevant drug history. The course of the disease was gainst Purpuric MF. An atypical presentation of PPD still likley, I suppose, but a really odd distribution and disease course. 

This leaves the possibility of a purpuric contact dermatitis, which on balance, is the best fit. Purpuric contact dermatitis can occur following exposure to a variety of allergens, including, textile dyes, rubber, components of washing powdres etc, which may explain distribution in areas with tight fitting of clothing. At the CPC meeting, a decision was taken to patch test and I await the results. I also took a second opinion from Dr Calonje and he pretty much rasied the the same d/d as considered above, but favoured purpuric contact dermatitis.

Thanks for all your comments. As I said, there is no firm bottom line here but I think you all have covered the entire d/d pretty well!

Babboon syndrome or SDRIFE did fit well with the clinical description and distribution of rash, but there was no relevant drug history. The course of the disease was gainst Purpuric MF. An atypical presentation of PPD still likley, I suppose, but a really odd distribution and disease course. 

This leaves the possibility of a purpuric contact dermatitis, which on balance, is the best fit. Purpuric contact dermatitis can occur following exposure to a variety of allergens, including, textile dyes, rubber, components of washing powdres etc, which may explain distribution in areas with tight fitting of clothing. At the CPC meeting, a decision was taken to patch test and I await the results. I also took a second opinion from Dr Calonje and he pretty much rasied the the same d/d as considered above, but favoured purpuric contact dermatitis.

Nice case Arti, could you keep us informed on the results of the patch test?