Saturday, July 04, 2015

A Diagnostic Dilemma

presented by Hamish Dunwoodie
Tracadie, New Brunswick

The patient is a 60 yo man who presented with a six months history of two asymptomatic erythematous nodules on the torso.  He has been in his usual state of health otherwise. No history of fever, chills or night sweats.

O/E:  There are two erythematous nodules located on the right abdomen and the left upper back.  They measure 3 - 4 cm in diameter. No other cutaneous findings.

Clinical Photos:

New Lesion 10.25,16 R, Upper Back)

A superficial and deep nodular and interstitial infiltrate of CD20 positive B-lymphocytes admixed with CD3 positive T-lymphocytes with slight preponderance of B-cells.  There is a scattering of CD30 positive lymphocyres.  There appears to be a Grenz zone.  Gene rearrangement studies are not indicative of either a clonal T or B cell lymphoproliferative disorder.


CD 3
CD 20
Lab: CBC, Chemistries, Serum protein electrophoresis all normal. IgG, IgM and IgG were all normal.

Diagnosis: The differential is between an atypical lymphoid infiltrate and a cutaneous lymphoma.  We are leaning towards the former.  Note: The last clinical photo was taken ~ 1 month after the others and shows progression.  We plan to excise this recurring tumor for help with diagnosis.

Should we treat? and if so how?
Should we follow with active surveillance?
Would any of you make a a more specific diagnosis?
Is any further testing indicated at this time?

Follow-up 2.3.16
The patient's lesions come and go.  All tests for systemic disease are negative.  New lesion (see photo) on left chest 2 cm in diameter seen today.  Will try to treat with clobetasol ointment.

10.16.16.  Old lesions have disappeared and new lesions develop.  Bo evidence of systemic disease.

1. Atypical lymphoid proliferations: the pathologist's viewpoint. Hussein MR. Expert Rev Hematol. 2013 Apr;6(2):139-53. doi: 10.1586/ehm.13.4.
Abstract: Lymphoid proliferations are traditionally thought to be either benign conditions (reactive hyperplasia and lymphadenitis) or malignant lymphomas. However, not all lymphoid lesions at present can be precisely placed into one of these categories. 

2. Cutaneous B-cell lymphomas: 2015 update on diagnosis, risk-stratification, and management. Wilcox RA.  Am J Hematol. 2015 Jan;90(1):73-6. Free Full Text Online.  


  1. Larry Gibson of the Mayo Clinic wrote: "In reference to the this patient, I think another consideration is CD4positive small/medium cell pleomorphic T cell lymphoma. These are often solitary and patients are OW healthy. There are typically a lot of CD20 B cells and molecular studies may be negative. The stains are PD1, CXCL13 and Bcl6 can be done looking for coexpression by the T cells.
    These lymphomas can be treated by excision or excision followed by localized radiotherapy.

  2. Khalife Sharquie from Baghdad, Iraq wrote: "The clinical picture is that of B cell lymphoma although pseudolyphoma might resemble thiscondition.Screening for visceral involvement is essential.strong topical steroid is enough and follow up for any further progression is mandatory."

  3. Andrew Carlson from Albany Medical Center (NY) wrote: "'s likely a cutaneous marginal zone lymphoma.

    In order to DX confidently, you have to the lymphoma work up/pane for cutaneous B cell lymphomas.

    Any tick bite history, Borrelia positive serology, and/or response to to antibiotic (doxycylcine) therapy?"

  4. Henry Foong of Ipoh Malaysia wrtoe: "tough one. cases nowadays are increasingly more of lymphomas nowadays. One has to be well verse with IHC as most cutaneous lymphomas need such special studies. i think this could be a CD20 positive T celll lymphoma ."

  5. From Barry Ladiainzki (Dermatology Resident in Chicago): “I can tell you from working with a national expert on lymphomas that with an atypical lymphoid infiltrate biopsy sans positive gene rearrangement studies. He would not treat as CTCL and likely just use topical steroids and monitor.
    He would also rarely use radiation for small lesions such as this (even B-Cell Lymphoma) and try topical nitrogen mustard, interferon or MTX, etc. before going to anything stronger."


We welcome your comments. We endeavor to serve your patients and you. If you want us to respond, please add your name and email address. Some people have trouble uploading comments. In that case, please send comments directly to Thank you.