Abstract

A 41-year-old male smoker with extensive prior travel to Haiti and multiple Asian countries developed painful, non-healing wounds along the right posterior thigh for 2 months. He was initially treated with incision and drainage, debridement and multiple courses of antibiotics. Upon referral to a dermatologist, examination revealed two adjacent ulcers, 8 cm and 5 cm, with fibrinous tissue at the base and violaceous, undermined edges. There was no lymphadenopathy. Punch biopsy from the edge and base of the ulcer demonstrated pseudoepitheliomatous hyperplasia and non-necrotizing granulomatous infiltrates. Tissue cultures were negative for fungi and mycobacteria. Progression of his wounds prompted additional biopsies, which showed an atypical lymphocytic infiltrate with large cells. Immunohistochemical stains were positive for CD2, CD43, EMA and CD30 and negative for ALK-1. Beta and gamma T-cell receptor genes were monoclonal. These findings were consistent with anaplastic large cell lymphoma (ALCL). A workup for systemic disease was negative; imaging was negative for nodal or metastatic disease. A diagnosis of primary cutaneous ALCL (pc-ALCL) was made, and the patient underwent local radiotherapy.

Granulomatous infiltrate in lesions of cutaneous lymphoma is an uncommon but well-recognized phenomenon. A prominent granulomatous reaction was observed in 1.8% of patients with cutaneous lymphoma; the same report observed that in approximately 30% of cases, a diagnosis of granulomatous dermatitis preceded the correct diagnosis for a period of 1 to 216 months. Also, expression of EMA in pc-ALCL is rare.

We highlight the importance of sequential biopsies and clinico-pathologic correlation in cases of “unusual” granulomatous dermatitis.