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Diffuse Poikilodermatous Patches in a Middle-aged Man

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A man in his 40s with a 5-year history of mildly pruritic poikilodermatous patches and thin plaques involving the bilateral axilla and groin presented with expanding lesions on both flanks. He had not received any prior treatment for the lesions. On examination, there were hypopigmented and hyperpigmented reticulated patches and thin, atrophic plaques covering more than 10% of the total body surface area involving the axilla, groin, and flanks bilaterally (Figure, A). No cervical, axillary, or inguinal lymphadenopathy was noted. Results from a comprehensive review of systems was unremarkable. Results from a complete blood cell count, erythrocyte sedimentation rate, and blood chemistry analyses were normal. A 6-mm punch biopsy specimen from the right flank was obtained for histopathological examination (Figure, B). Immunohistochemical analysis was also performed (Figure, C and D).

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A. Mycosis fungoides

Histopathologic findings revealed a superficial perivascular and interstitial atypical lymphocytic infiltrate containing convoluted nuclear features in the lower epidermis and scattered in the epidermis above the basal cell layer (epidermotropism). These findings were consistent with patch-stage mycosis fungoides (MF). Immunohistochemistry analysis revealed cells that were diffusely reactive for CD3 (Figure, C), with significant loss of CD7 expression and no evidence of CD20 or CD30. T-cell receptor (TCR) gene rearrangement studies did not detect clonal TCR populations. There was a predominance of CD8-positive cells (Figure, D) over CD4-positive cells, which in conjunction with the clinical features was consistent with the diagnosis of poikilodermatous mycosis fungoides (PMF) stage IB disease. The patient is being treated with narrowband UV-B (nbUVB) phototherapy and is experiencing considerable improvement of the lesions.

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Article Information

Corresponding Author: Marcia S. Driscoll, MD, PharmD, General Dermatology Practice, University of Maryland School of Medicine, 419 W Redwood St, Ste 240, Baltimore, MD 21201 (mdriscoll@som.umaryland.edu).

Published Online: June 19, 2019. doi:10.1001/jamadermatol.2019.1525

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information and Puja K. Puri, MD, Labcorp-Center for Molecular Biology and Pathology for contributing the immunohistochemical staining images.

References
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