Asymptomatic Macules and An Ulcerated Shoulder in an Elderly Woman

Antonio Giovanni Richetta, MD, PhD; Simona Giancristoforo, MD; Carlo Mattozzi, MD; Sara D'Epiro, MD; Stefano Calvieri, MD


December 09, 2016

Physical Examination and Workup

Blood tests performed during her hospitalization show no abnormal values. During her hospital stay, cultures and microscopic evaluation of the wound exudate are found to contain coagulase negative-Staphylococcus and 2 separate Pseudomonas aeruginosa strains. Based on these observations, the patient is treated with intravenous antibiotic therapy (cefepime) for 10 days and advanced topical dressings. A skin biopsy of the ulcer shows an atrophic epidermis and an infiltrate of lymphocytes at the dermal-epidermal junction, with marked epidermotropism. Both immunohistochemical staining and flow cytometric analysis reveal neoplastic cells positive for CD3+, CD8+, CD30+, and negative for CD4, CD56, with several cells CD20+.

The patient then undergoes brain, chest, abdomen, and pelvis CT scans, which reveal bilateral subcentimetric lymph nodes in the laterocervical area, a patchy thyroid, small ilo-mediastinal lymph nodes, and a 20-mm lymph node in the right axilla with conserved morphology, as well as some lymph nodes in the left axilla of varying size (maximum 15-mm diameter). The liver does not have vascular abnormalities. The patient undergoes an ultrasound of the abdomen showing a spleen that is increased in volume at the upper reference range limit (4 cm), small exorenal cystic lesions, and small subcentimetric lymph nodes in the retroperitoneal lumboaortic space and bilateral inguinal areas. A bone marrow biopsy does not show any pathologic features. A SPECT scan highlights increased pathologic metabolism at a right parapharyngeal lymph node and superficial soft tissues of the right shoulder, left lower extremity, and back.


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