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LETTER TO THE EDITOR
Year : 2014  |  Volume : 5  |  Issue : 2  |  Page : 224-226  

Idiopathic cutaneous pseudolymphoma: An enigma


Department of surgery, Bharati Medical College, Sangli, India

Date of Web Publication21-Apr-2014

Correspondence Address:
Vinod Prabhu
Sangli Shreyas, Behind Central Warehouse, Miraj - 416 410
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.131143

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How to cite this article:
Prabhu V, Shivani A, Pawar VR. Idiopathic cutaneous pseudolymphoma: An enigma. Indian Dermatol Online J 2014;5:224-6

How to cite this URL:
Prabhu V, Shivani A, Pawar VR. Idiopathic cutaneous pseudolymphoma: An enigma. Indian Dermatol Online J [serial online] 2014 [cited 2019 Dec 7];5:224-6. Available from: http://www.idoj.in/text.asp?2014/5/2/224/131143

Sir,

Pseudolymphoma is not a specific disease but an inflammatory response to known or unknown stimuli that results in a lymphomatous-appearing picture, mimicking lymphoma but in fact a benign accumulation of inflammatory cells. However, the terminology of pseudolymphoma should be reserved for idiopathic cases where inciting cause is unknown. The enigma stems from the fact that the condition has to be differentiated from cutaneous lymphoma which would change the outcome of the disease.

This case presented as a pigmented nodule just above left ala of nose since 2 years resembling a nevus in a middle-aged male which was asymptomatic [Figure 1]. The patient gave a history of recent increase in size since 2 months with no pain, discharge, and itching. On examination, it was a firm red-brown nodule, non-tender with no regional lymph nodes palpable. There was no history of insect bite, trauma, and infection at that site in the past. There was no history of drug ingestion. A wide excision was done; the histopathology was reported as cutaneous pseudolymphoma. At 6-month follow-up, patient was asymptomatic. Immunohistochemistry revealed negative  CD3, CD10, leucocyte common antigen (LCA), and CD20 panel, which are markers for lymphoma. After ruling out all etiological factors mentioned above and the histological evidence of top heavy dermal, mixed cellular infiltrate, absence of pigmentation and blast cells, with no necrotic areas, it was labeled as idiopathic pseudolymphoma.
Figure 1: Nodular lesion over left ala of nose

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Pseudolymphoma, also called as cutaneous lymphoid hyperplasia, is a skin lesion having lymphomatous appearance mimicking lymphoma that results from known or unknown stimulus like insect bites, vaccination, trauma, folliculitis, drugs, jewelry, and contactants. [1],[2] This results in accumulation of inflammatory cells that not only mimics lymphoma histologically but clinically as well. Nodular lesions resemble B-cell lymphomas, whereas plaque forms resemble T-cell lymphomas. It is essential to differentiate pseudolymphomas from malignant lymphomas, which involves clinical, histological, and immunohistochemistry evidences as even in benign lesions, malignant histological picture may be seen.

Pseudolymphomas are classified according to histological components into B-cell and T-cell variants. Commonly occurring etiological causes have been tabulated along with salient histological features  [Table 1]. Cutaneous lymphomas are classified according to  EORTC classification. [3]
Table 1: Classification of cutaneous pseudolymphomas

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Immunohistochemistry [4] forms the mainstay of differentiation in a rural setup where advanced laboratory techniques are unavailable. Minimum immunohistochemistry for any suspected hematolymphoid lesion is CD10, LCA, CD20, and CD3. CD20 is for B-cell expression, CD3 for T-cell expression and T cell germinal center, and CD10 for B-cell germinal center. In this case, CD3, CD10, LCA, and CD20 were negative, thus suggesting benign nature of the lesion  [Figure 2]a-d. Techniques such as immunophenotyping staining patterns are done to diagnose lymphomas. [5]

The diagnosis poses a challenge more to pathologists, as the pattern of mixed infiltrate that includes histiocytes, eosinophils, and plasma cells is significant. Polymorphous infiltrates, lack of atypical lymphocytes, and dominant lymphocytic clones are highly suggestive of pseudolymphomas [6] [Figure 3]. The infiltrate tends to be "top-heavy," in pseudolymphomas, whereas in most lymphomas, they are centered in the deep dermis. The LCA also forms a major source of differentiation, as it is negative in pseudolymphomas and strongly positive in lymphomas.
Figure 2: ×40 Immunohistochemistry stains using LCA, CD3, CD10, CD20 antibodies. (a) Leucocyte common antigen shows positivity for lymphocytes indicating predominant lymphocytic lesion (b) CD3 shows positivity for T cells but the larger cells are negative for the stain (c) CD10 shows positivity for B cells (d) CD20 shows Positivity for B cells. The larger cells are negative for the stains

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Figure 3: (a) top heavy infiltrate rich in small T lymphocytes with admixed, scattered T and B immunoblasts, histiocytes, and plasma cells. (H and E, ×10) (b) High-power field showing mixed infiltrate of T and B cells, histiocytes, and plasma cells (H and E, ×40)

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In conclusion, pseudolymphomas form a diagnostic challenge in rural medical college hospital with limited resources for advanced investigations. A proper history to rule out etiology, careful histological evaluation along with judicious immunohistochemistry panel suffices, to diagnose pseudolymphomas. In many cases, a proper etiology may not be elicitable leading to labelling these cases idiopathic. [7],[8] A follow-up of at least 5 years is required to rule out risk of cutaneous lymphomas.

 
   References Top

1.Shtilionova S, Drumeva P, Balabanova M, Krasnaliev I. What is pseudolymphoma and its nature. J IMAB-Annual Proceeding (Scientific Papers) 2010;16:Book 3.  Back to cited text no. 1
    
2.Bergman R. Pseudolymphoma and cutaneous lymphoma: Facts and controversies. Clin Dermatol 2010;28:568-74.  Back to cited text no. 2
[PUBMED]    
3.Willemze R, Kerl H, Sterry W, Berti E, Cerroni L, Chimenti S, et al. EORTC classification for primary cutaneous lymphomas: A proposal from the Cutaneous Lymphoma Study Group of the European Organization for Research and Treatment of Cancer. Blood 1997;90:354-71.  Back to cited text no. 3
    
4.Hasan M, Shahid M, Varshney M, Mubeen A, Gaur K. Idiopathic lymphocytoma cutis: A diagnostic dilemma. BMJ Case Rep 2011; bcr1220103662.  Back to cited text no. 4
    
5.Bergman R, Khamaysi K, Khamaysi Z, Ben Arie Y. A study of histologic and immunophenotypical staining patterns in cutaneous lymphoid hyperplasia. J Am Acad Dermatol 2011;65:112-24.  Back to cited text no. 5
    
6.Bergman R, Khamaysi Z, Sahar D, Ben-Arieh Y. Cutaneous lymphoid hyperplasia presenting as a solitary facial nodule: Clinical, histopathological, immunophenotypical, and molecular studies. Arch Dermatol 2006;142:1561-6.  Back to cited text no. 6
    
7.Ploysangam T, Breneman DL, Mutasim DF. Cutaneous pseudolymphomas. J Am Acad Dermatol 1998;38:877-95.  Back to cited text no. 7
    
8.Stephen J, Shwartz RA. Plasma cell predominant Bcell pseudolymphoma. Dermatol Online J 2008;14:12.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]


This article has been cited by
1 Cutaneous Pseudolymphomas
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Actas Dermo-Sifiliográficas (English Edition). 2016;
[Pubmed] | [DOI]
2 Pseudolinfomas cutáneos
D. Romero-Pérez,M. Blanes Martínez,B. Encabo-Durán
Actas Dermo-Sifiliográficas. 2016;
[Pubmed] | [DOI]



 

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