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Generalized Asymptomatic Skin Nodules in a Young Man

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

A 29-year-old man presented with a 2-month history of rapidly growing, widespread, asymptomatic skin nodules all over his body. He denied having fever, chills, fatigue, night sweats, or weight loss. He had no history of malignant neoplasm or chemical exposure. Physical examination findings demonstrated numerous erythematous, indurated nodules involving the surface of his head, neck, torso, and extremities, without ulceration or scarring (Figure, A and B). Findings of systemic reviews were unremarkable, and there was no lymphadenopathy or peripheral nerve enlargement. Complete blood cell count with differential results were normal (white blood cell count, 6060/μL, normal range, 4500-10 000/μL; absolute neutrophils, 3070/μL, normal range, 1800-8300/μL [to convert cell counts to ×109/L, multiply by 0.001]). Serum lactate dehydrogenase level was elevated (279 U/L, normal range, 100-240 U/L [to convert to μkat/L, multiply by 0.0167]). Biopsies from skin nodules (Figure, C) and bone marrow were obtained.

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A. Aleukemic cutaneous myeloid sarcoma

Skin biopsy results revealed diffuse, nonepidermotropic infiltrate of atypical mononuclear cells involving the entire dermis and extending to the subcutis (Figure, C). The infiltrating cells were medium sized, round to oval, with slightly eosinophilic cytoplasm and distinct oval-shaped or kidney-shaped basophilic nuclei. They stained positively for CD45, MPO, KP-1, and CD43 and were negative for CD3, CD123, CD20, CD34, CD56, CD117, and CD138, compatible with primitive myeloid cells. Mitotic figures were noted. Bone marrow biopsy results showed no evidence of leukemic involvement. Results of subsequent fluorescence in situ hybridization analysis performed on paraffin sections of the skin biopsy did not reveal 11q23/MLL rearrangement or t(8;21)(q22;q22.1) rearrangement. Neither NPM1 nor FLT3 variation was detected in the skin lesion.

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Article Information

Corresponding Author: Yang Wang, MD, Department of Dermatology and Venereology, Peking University First Hospital; Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, No. 8 Xishiku St, Xicheng District, Beijing 100034, PR China (yangwang_dr@bjmu.edu.cn).

Published Online: January 28, 2021. doi:10.1001/jamaoncol.2020.6728

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

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