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Abstract

A 68-year-old woman with a history of breast cancer presented with a 10-month history of recurrent necrotic papules and plaques on breast, trunk, and extremities. Most lesions ranged from a few millimeters to 1.5 cm; however, one lesion on the wrist measured 2.4 cm. Prior biopsies of resolving lesions were non-diagnostic. She was treated with dapsone, which was discontinued due to anemia, leading to a flair of necrotic lesions. Two 4mm punch biopsies, one from the wrist and one from the hip, were obtained. Histologic examination revealed epidermal necrosis with a dense superficial and deep perivascular and interstitial mixed infiltrate of lymphocytes, histocytes, neutrophils, and numerous eosinophils. Medium to large-sized atypical cells with vesicular nuclei, irregular contours, and with occasional prominent nucleoli were identified. Mitotic figures and extensive coagulative necrosis were present. These atypical cells were positive for CD8, CD3, CD2, granzyme B, and perforin, and negative for CD4, ALK and TIA1. EBER in situ hybridization was negative. The histopathologic differential diagnosis was a CD30 positive T- cell lymphoproliferative disorder such as lymphomatoid papulosis (LyP), primary cutaneous anaplastic large cell lymphoma, and extranodal NK/T cell lymphoma, nasal type. Given the clinical history of recurrent and resolving lesions, combined with the histologic findings of coagulative necrosis and CD8 positivity, a diagnosis of LyP specifically the angiodestructive, CD8 positive LyP type E was favored. This case highlights the importance of correlating clinical and histologic findings, avoiding biopsies of resolving lesions when possible, and maintaining a high suspicion of LyP in atypical presentations.