Internal Medicine Section DOI : 10.7860/JCDR/2015/14326.6391
Year : 2015 | Month : Aug | Volume : 9 | Issue : 8 Page : OJ01 - OJ01

An Unusual Presentation of Chronic Lymphocytic Leukaemia

Kavita Paul1, Geetika Paul2, Harbans Lal Kazal3, Nariender Kumar Bairwa4

1 Assistant Professor, Department of Medicine, GGS Medical College & Hospital, Faridkot, Punjab, India.
2 Senior Resident, Department of Dermatology, SMS Medical College, Rajasthan, Jaipur, India.
3 Professor, Department of Medicine, GGS Medical College & Hospital, Faridkot, Punjab, India.
4 Resident, Department of Medicine, GGS Medical College & Hospital, Faridkot, Punjab, India.


NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Kavita Paul, 639, Urban Estate Phase II, Jalandhar-144001, Punjab, India.
E-mail: kavitapaul83@gmail.com
Abstract

Skin infiltration in Chronic Lymphocytic Leukemia (CLL) is uncommon and can present in many different ways. Cutaneous CLL deposits develop most commonly on the face, but localized lesions can occur at other sites also and manifest as macules, papules, plaques, nodules, tumours, ulcers or blisters. Evident skin involvement is usually seen in Richter syndrome or T–cell CLL and it generally indicates a poor prognosis [1,2].

We present a case of CLL infiltrating multiple body areas. A 45-year-old, male patient, presented with complaint of skin rash over face, neck and forearms since last 9 months [Table/Fig-1,2]. The rash was present only over the sun exposed parts of the body like face, neck, forearm and hands and was associated with redness and itching. History of decreased appetite and weight loss was present since 4 months. Examination revealed generalized lymphadenopathy [Table/Fig-3] and erythematous papules and plaques on face, neck and dorsum of hands with hepatosplenomegaly. Complete blood counts showed Hb levels of 9.6 g/dl, TLC of 1.6 lac/mm3, DLC with 94% lymphocytes, 4% of promyelocytes, 1% of neutrophils and 1% basophils and platelets of 68000/mm3 and peripheral blood film was suggestive of marked leucocytosis. Bone marrow examination confirmed the diagnosis of CLL. Skin biopsy from the face showed abnormal lymphocytes infiltrating the dermis and subcutaneous tissue, suggesting skin infiltration by CLL [Table/Fig-4]. Patient was referred to oncologist and started on Chemotherapy.

Showing of nodular swelling on skin of face

Showing erythematous papules and plaques on both hands

Showing cervical lymphadenopathy

Skin biopsy showing abnormal lymphocytes infiltrating dermis

Infiltrative CLL can involve the head and neck, but involvement of multiple body areas, particularly toes and fingers is rare. The mechanism of cutaneous infiltration of leukemic cells is not well understood. Generally accepted theory is that, there is migration of lymphocytes from the vasculature to the dermis in CLL that is mediated by interaction between intercellular adhesion molecule-1 (ICAM-1) and lymphocyte function associated antigen-1 (LFA-1) [3]. Our patient had cutaneous infiltration as a first presenting symptom and had cutaneous infiltration not only on face and neck, but also on fingers and toes, which is rarely seen.

References

[1]Colburn DE, Welch MA, Giles FJ, Skin infiltration with chronic lymphocytic leukemia is consistent with a good prognosis Hematology 2002 7:187-88.  [Google Scholar]

[2]Watson KM, Mufti G, Salisbury JR, du Vivier AW, Creamer D, Spectrum of clinical presentation, treatment and prognosis in a series of eight patients with leukaemia cutis Clin Exp Dermatol 2006 31:218-21.  [Google Scholar]

[3]Cerroni L, Zenahlik P, Höfler G, Kaddu S, Smolle J, Kerl H, Specific cutaneous infiltration of b B cel llymphocytic leukemiaA clinicopathologic and prognostic study of 42 patients American Journal of Surgical Pathology 1996 20:1000-101.  [Google Scholar]