Atypical Lymphocytic Infiltrate

Presented by:
Ron Yaar, Boston University Skin Path and D.J. Elpern


Abstract:  50 yo man with few month history of an asymptomatic nodule on the scalp.

HPI: This 50 yo man has had a slowly enlarging tumor of the mid parietal scalp for three to four months.  No other similar lesions.  He has Type II diabetes and hypertension.  Meds: furosemide, metformin, Diovan, atenolol.


O/E: 15/6/2010  6-7 mm papule w/o diagnostic features mid-parietal
         15/7/2010 (reevaluation) 8 mm firm pink papule.  Difficult to see because covered with hair.

Clinical Photo: 

Pathology:

Image HE – 20x -  Dense, pandermal lymphocytic infiltrate.  Focal crush cell artifact at edges.
Image HE – 100x – A mixed population of cells.  A clear Grenz zone is present.
Image HE – 400x – Smaller lymphocytes mixed with highly pleomorphic cells.
Photos courtesy of Ron Yaar, M.D.

CD3 – Numerous T lymphocytes present.  Higher mag shows that most are smaller cells.
CD20 – Numerous B lymphocytes present.  Higher mag shows many of them correspond to the larger, pleormorphic cells.

H & E  20x

H & E 100x

H & E 400 x

CD 3  40x

CD 3 400x

CD 20  40x

CD 20  400x

Lab:  At this point we don't have any lab results. Will check on his latest CBC.

Diagnosis:  Solitary Atypical Lymphoid Infiltrate.  Benign or Malignant?

Questions:  Have you seen a similar case?  Could this be a reaction to a bite?  How would you approach this?

References:
1. Talpur R, Duvic M.  Atypical lymphoid infiltration occurring at the site of a healed varicella zoster infection.  Clin Lymphoma. 2003 Mar;3(4):253-6.
Abstract:  Herpes zoster infection has been associated with a number of cutaneous reactions. The authors report the first case of a patient with an atypical epidermotropic lymphoid infiltrate that arose within skin previously affected by herpes varicella zoster. The differential diagnosis of such lesions and review of literature on previous cutaneous infiltrates occurring at sites of zoster infection are discussed.