Case Number : Case 1953 - 23 Nov 2017 Posted By: Uma Sundram

Normal stratum corneum, subtle interface change and upper dermal perivascular and perifollicular lymphocytic infiltrate suggest a drug hypersensitivity syndrome and the mucosal lesions could be a part of it. Some lymphocytes appear to be abnormally large. ? Drug induced pseudolymphoma. Has the patient received anticonvulsants?

Agree with the normally basket-weave stratum corneum making unlikely MF, but I think also MF in early stages could be looking as this case. So my first spot is MF, folliculotropic variant.

The patient is in the ICU most probable cause is drug induced rash.

14 minutes ago, Raul Perret said:

The patient is in the ICU most probable cause is drug induced rash.

Yes. Agree. I was only talking about morphological spot impression. I know drug induced folliculotropic lymphocytic infiltrate may be very atypical. 

Subtle interface and features described above. Drug reaction most likely.

Drug rash

Drug Rash

I see a lot of lymphoid apoptosis (clues to lupus, kikuchi and lymphoma). Not much actual necrosis on the keratinocytes compared with the density of infiltrate.

I struggled with lymphoid atypia here and need a thin H&E but thought there were some atypical lymphoid cells.

I like the suggestion of a "pseudolymphomatous" drug rash certainly fits well with "new" onset.

I'd wonder about infections including viruses. I'd also consider a lymphoma in the DDx.

Sadly there appear to be at least 55 causes of glossitis (including infections & drugs) so I found this clue not too helpful.

Causes of erythroderma certainly includes drugs (top of the list I guess for new onest), Sezary (which histologically is a possibility but "new" onset) and even rarely HIV.

Not sure histology helps much though as we still have the same conundrum and suspect the clinical will work it out!

Patient has a prior h/o seizures and was on anti convulsants, which initiated the rash. Drug induced pseudo lymphoma. Patient also had elevated AST and ALT due to the medication and was waiting to be transported for work up for liver transplant. Based on the diagnosis, the drug was stopped and the patient left the hospital 2 weeks later, liver intact.