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LETTER TO THE EDITOR
Year : 2016  |  Volume : 7  |  Issue : 2  |  Page : 134  

Multiple erythematous nodules in a 30-year-old woman


Department of Dermatology, Employees State Insurance Post Graduate Institute of Medical Sciences and Research, New Delhi, India

Date of Web Publication4-Mar-2016

Correspondence Address:
Dr. Shikha Gupta
Department of Dermatology, Employees State Insurance Post Graduate Institute of Medical Sciences and Research, Basaidarapur, New Delhi - 110 015
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.178095

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How to cite this article:
Gupta S, Dísouza P, Dhali TK. Multiple erythematous nodules in a 30-year-old woman. Indian Dermatol Online J 2016;7:134

How to cite this URL:
Gupta S, Dísouza P, Dhali TK. Multiple erythematous nodules in a 30-year-old woman. Indian Dermatol Online J [serial online] 2016 [cited 2020 Apr 2];7:134. Available from: http://www.idoj.in/text.asp?2016/7/2/134/178095

Sir,

We write this letter in response to the article titled “Multiple erythematous nodules in a 30-year-old woman,” published in your esteemed journal in the May–June 2015 issue in the quiz section.[1]

According to the authors, the female patient presented with a two month history of red-brown and violaceous nodules over face, earlobes, chest, back, and upper extremities. Apart from two enlarged lymph nodes over the left cervical region, there were no systemic findings. Her complete blood count showed mild anemia and was otherwise healthy. Skin biopsy stained with hematoxylin and eosin (H and E) revealed periadnexal and deep dermal B-cell-type lymphoblastic infiltrate and there was diffuse staining of cells with terminal deoxynucleotidyl transferase (TdT). Subsequently, the authors diagnosed her as acute lymphoblastic leukemia (ALL) with cutaneous infiltration.

We would like to point out in this regard that the diagnosis of ALL should not be made in the absence of a peripheral smear and a bone marrow aspiration and biopsy. Although white blood cell count may be normal in these patients, National Comprehensive Cancer Network (NCCN) guidelines note that diagnosis of ALL generally requires the following:[2]

  1. Demonstration of ≥20% bone marrow lymphoblasts
  2. Morphologic assessment of Wright/Giemsa–stained bone marrow aspirate smears
  3. H and E–stained bone marrow core biopsy and clot section
  4. Comprehensive flow cytometric immunophenotyping.


Thus, bone marrow aspiration and biopsy are the definitive diagnostic tests to confirm the diagnosis of leukemia, a fact acknowledged by the authors in their discussion.

TdT is a DNA polymerase enzyme, which is expressed in undifferentiated clones of migrating lymphoid cells.[3] Although most cases of ALL are positive for TdT, the latter is not specific for ALL. High levels of TdT are also encountered in chronic myelogenous leukemia (CML), a number of acute undifferentiated leukemia (AUL) and lymphoblastic lymphomas.[3]

Out of the lymphoblastic lymphomas, precursor B-lymphoblastic lymphoma (P-LBL) usually involves skin, soft tissue, bone, and lymph nodes.[4] Therefore it may also be considered as a differential in this case.

In the scenario of peripheral blood smear and bone marrow aspiration being noncontributory, the diagnosis then considered in this case would be “Aleukemic leukemia cutis,” a condition where skin involvement by leukemic cells precedes peripheral blood or bone marrow involvement.[5]

Because an accurate diagnosis of subtype of leukemia/lymphoma will lead to appropriate management of such a case, we wish to reiterate the importance of a peripheral blood smear and a bone marrow aspiration and biopsy to make a diagnosis of lymphoma/leukemia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
García-Meléndez ME, Eichelmann K, Vázquez-Martínez OT, Ocampo-Candiani J. SkIndia Quiz 18: Multiple erythematous nodules in a 30-year-old woman. Indian Dermatol Online J 2015;6:228-9.  Back to cited text no. 1
    
2.
[Guideline] NCCN Clinical Practice Guidelines in Oncology: Acute Lymphoblastic Leukemia, Version 2:2014. National Comprehensive Cancer Network. Available from: http://www.nccn.org/professionals/physician_gls/pdf/all.pdf. [Last accessed on 2015 Aug 5].  Back to cited text no. 2
    
3.
Vezzoni P, Campagnari F, Di Fronzo G, Clerici L. Terminal deoxynucleotidyl transferase in human lymphomas: Possible existence of forms with high and low molecular weights. Br J Cancer 1981;43:312-9.  Back to cited text no. 3
    
4.
Wang RC, Jan YJ, Wen MC, Wang J, Hsieh PP. Primary appendiceal precursor B lymphoblastic lymphoma with peculiar morphology mimicking diffuse large B cell lymphoma. Pathol Int 2010;60:690-3.  Back to cited text no. 4
    
5.
Hejmadi RK, Thompson D, Shah F, Naresh KN. Cutaneous presentation of aleukemic monoblastic leukemia cutis - a case report and review of literature with focus on immunohistochemistry. J Cutan Pathol 2008;35(Suppl 1):46-9.  Back to cited text no. 5
    




 

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