Track: Case Reports

Abstract:

37-year-old man presented to the ambulatory care with fever, chills, headache, myalgia, and skin rash. The patient denied weight loss, ill contacts, recent travel, outdoor activities, or tick bite. Physical examination revealed a fatigued patient with diffuse erythematous rash of non-blanching small papules and macules involving both legs and feet in a sock distribution. Lymphadenopathy, hepatomegaly, or splenomegaly were not present. Complete blood count (CBC) revealed low platelet count (122,000/mcl) which triggered review of the peripheral blood smear and lead to detection of large atypical cells. Review of peripheral blood smear described the large cells as probable immunocytes (8%); flow cytometry phenotyped them as large suppressor T-cells (CD2(+),CD3(+),CD8(+),CD4(-),CD5(+),CD7(+) ,CD25(-), CD56(-) CD57(-)). Serology for Hepatitis A, B, and C, Epstein Barr Virus, and PCR for Cytomegalovirus, Influenza, Respiratory Syncytial Virus, and COVID-19 were negative. A skin punch biopsy from the leg rash revealed perivascular infiltrate of lymphocytes, neutrophils, nuclear debris, and erythrocytes, consistent with leukocytoclastic vasculitis. This result raised pathologist’s concern for “Gloves and Socks Syndrome” associated with Parvovirus B19 infection. Serum Parvovirus B19 IgM was high confirming this diagnosis. The “atypical lymphocytosis” was felt to represent reactive lymphocytosis secondary to viral infection, however, to exclude a lymphomatous process, PCR for T-cell receptor gene rearrangement was performed which showed two clones. While the PCR result does not confer a definitive diagnosis of lymphoma, given that clonal proliferation of lymphocytes can be transient and seen in reactive lymphocytosis, the patient was advised to follow-up with repeat CBC and peripheral blood smears.

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Yu Zhang