Clinical image description

A partialy dependent 76-year-old female with medical history of rheumatoid arthritis treated with methotrexate 2.5 mg 3 pills once weekly, dyslipidemia treated with atorvastatin 10 mg QD, aortic stenosis, and bipolar disorder treated with sodium valproate 250 mg TID and bupropion 300 mg QD, presents to the geriatric appointment, where she’s being followed in order to manage her multiple comorbidities and prevent further frailty, with erythematous plaques and nodules spread through the upper (Figure 1) and lower limbs, with ulcerated nodules in the lower limbs (Figure 2). Given the immunosuppression context and the suggestive aspect, an excisional biopsy was required showing a dense dermal infiltrate comprised of cohesive sheets of intermediate to large CD30 positive cells with prominent nucleoli. The other immunohistochemical studies revealed also cells CD3+, CD20-, CD2+, CD4+, CD8-, CD5+, CD7+, ALK-, EBER- and CD56-. All these aspects were compatible with Primary Cutaneous Anaplastic Large Cell Lymphoma (PC-ALCL). The chest, abdomen and pelvis CT excluded systemic disease and the patient refused to undergo bone marrow biopsy and aspirate (the utility of this last one being debatable in the absence of clinically or radiographically detectable disseminated disease). She continued on methotrexate as the preferred initial systemic therapy for PC-ALCL but needed also a systemic corticosteroid, deflazacort 15 mg, to attain disease stability (Figure 3). This case reports a rare condition, presenting with multifocal disease and in a woman, which is even rarer, to remind us of its existence but also to have in mind that the key to the management of patients with PC-ALCL, besides monitoring disease extension, is to avoid overtreatment.