mycosis fungoides ( mf ) is the most common type of cutaneous t - cell lymphoma ( ctcl ) which typically affects older adults . early typical lesions in mf are variably sized erythematous finely scaling lesions , which may be mildly pruritic ; as the lesions progress , they become infiltrated , reddish - brown scaling plaques . granulomatous mycosis fungoides ( gmf ) is a rare type of cutaneous t cell lymphoma . no particular clinical criteria are available for the diagnosis of gmf because of its variable presentations ; therefore , detecting gmf is primarily considered as a histopathological diagnosis . rarely , the co - existence of more than one clinical or histopathological feature of mycosis fungoides may be present . to the best of our knowledge this is the first report of mf that shows the simultaneous co - existence of more than one clinical and histopathological variant of mf . we describe a 29-year - old female with various clinical lesions of mf , i.e. , the erythematous scaly and hypopigmented patch lesions , and also the different histopathological features of the disease such as the granulomatous and classic variants . a 29-year - old iranian woman was referred to the al - zahra hospital mf clinic which is an academic referral center for cutaneous lymphoma of isfahan university of medical sciences , iran . she had had a history of developing bilaterally nonpruritic erythematous and hypopigmented patches on both the arms and axillary areas for 3 years . at the time of referral , she had hypopigmented and depigmented macules and patches ( pityriasis versicolor - like lesions ) [ figure 1 ] , erythematous scaly plaques , and a few small nodules ( < 1 cm ) on the upper and lower extremities , flanks , buttocks , abdomen , and both axillary areas [ figures 1 and 2 ] . body surface area involvement was about 30% . on physical examination , no lymphadenopathy or organomegaly was detected . four skin biopsies were obtained from four different anatomic sites with different clinical pictures ( 1 - left flank : erythematous patch , 2 - left buttock : erythematous plaque , 3 - left inner aspect of thigh : erythematous patch and 4 - left arm : hypopigmented patch ) and immunohistochemical ( ihc ) studies were performed on paraffin sections too . histopathological examination confirmed the diagnosis of mf in all of the specimens and , in addition , ihc staining supported this diagnosis [ figures 3 and 4 ] . interestingly , the specimen , which had been obtained from the erythematous patch of the inner thigh , showed granuloma formation in some areas and these findings were consistent with the mf granulomatous variant [ figures 5 ] . so our clinical suspicion of mf was confirmed by the results of pathology and ihc staining . the complete blood count , peripheral blood smear , blood chemistry panel , and liver function tests were normal . the ldh level was 241 iu / l ( normal range : 225 - 450 ) . she was treated with phototherapy and advised to pursue regular follow - up sessions for the monitoring of her condition . erythematous patches and plaques on left flank and buttock , and hypopigmented patches on the left arm histopathological feature of the patch stage of mycosis fungoides . sections from the left arm ( hypopigmented ) patch show epidermotropism of atypical lymphocytes , mostly in basal layer and dermis , mild interstitial infiltrate of small lymphocytes seen ( h and e100 ) histopathological feature of mycosis fungoides . upper dermis reveals prominent fibrosis with thick and wiry collagen bundles in haphazard directions intermingled with a moderately dense and band - like infiltration of atypical lymphoid cells ( h and e100 ) granulomatous mycosis fungoides . moderately dense infiltration of small - to medium - sized atypical lymphocytes in dermis with irregular and convoluted hyperchromatic nuclei admixed with some histiocytes and multiple multinucleated giant cells ( arrows show the granulomas and multinucleated giant cells ) producing ill - defined nonnecrotizing granulomatous aggregates and extending form superficial dermis down to deep reticular dermis . also phagocytosis of atypical lymphocytes by multinucleated giant cells ( h and e100 ) mf is the most common type of ctcl which is responsible for nearly 50% of all primary cutaneous lymphomas . although mf is a rare disorder of older adults ( 55 - 60 years ) with a 2:1 male : female ratio , our patient was young and female . in an epidemiologic study that we performed in isfahan , iran , the mean age of patients with mf was 43.14 years and the male : female ratio was 3:4 . thus it seems that , on average , iranian patients are younger than patients in the west and the number of female cases is higher . classic clinical presentations of mf are erythematous scaling patches and plaques which may progress to nodules and tumors . typical histopathology of early lesions shows superficial band - like or lichenoid infiltrates , mainly composed of lymphocytes . atypical lymphocytes with small to medium - sized , highly convoluted ( cerebriform ) , and sometimes hyperchromatic nuclei are few , and are mostly confined to the epidermis ( epidermotropism ) . the presence of intraepidermal nests of atypical cells ( pautrier 's microabscesses ) is highly characteristic but is only seen in a minority of patients . clinical variants of mf such as bullous , hyper , or hypopigmented mf are histopathologicaly similar to classic mf and are not considered separately . primary lesions may present in the ages ranging between 2 and 19 years , but histologic diagnosis may be delayed until 2 - 10 years later . its usual presentation is scattered hypopigmented macules or large patches on the trunk and the extremities . hypopigmented lesions are generally asymptomatic , nonatrophic , and nonscaly and nonpruritic , but itching may occur in some cases such as that in work by topar et al . describe a case of a 24-year - old male , with asymptomatic vitiligo - like skin lesions harboring the characteristics of mycosis fungoides and lesions with the characteristics of large plaque parapsoriasis , developing over preexisting hypopigmented lesions , as the presentation of unusual clinical features and conspicuous histopathological findings . in our case , hypopigmented lesions also were seen coexisting with instances of early patch and plaque . the typical histologic feature of mf usually shows epidermotropism by abnormal lymphocytes and sometimes pautrier microabscesses . granulomatous mycosis fungoides ( gmf ) is a rare histological variant of ctcl without clinical distinction from classic mf . due to the variable presentations of gmf , no particular clinical criteria are available for the diagnosis of gmf ; therefore , detecting gmf is primarily considered as a histopathological diagnosis . in our case the erythematous patch of the inner thigh showed granuloma formation in some areas and these findings were consistent with the mf granulomatous variant . so in this report , we described a patient with the clinical features of both classic and hypopigmented mf and the histological features of classic mf and also the granulomatous variant of the disease . to the best of our knowledge , in the literature , there is no other case with various clinical and histopathological presentations of mf present simultaneously in one patient . to the best of our knowledge , there is no other case with various clinical ( classic and hypopigmented ) and histopathological ( classic and granulomatous types ) presentation simultaneously in one patient .
mycosis fungoides is the most common type of cutaneous t - cell lymphoma ( ctcl ) and a rare disorder that typically affects older adults with erythematous scaling patches and plaques . 
 hypopigmented patches are a rare clinical variant of the disease . 
 granulomatous mycosis fungoides ( gmf ) is also a rare type of ctcl . 
 no particular clinical criteria are available for the diagnosis of gmf , because of its variable presentations , and so the detection of gmf is primarily considered as a histopathological diagnosis . 
 rarely , a co - existence of more than one clinical or histopathological feature of mycosis fungoides may be present . 
 to the best of our knowledge this is the first report of mf that shows the simultaneous co - existence of more than one clinical and histopathological variant of mf . 
 we present a 29-year - old female with clinical presentations of both classic and hypopigmented mycosis fungoides ( mf ) , and also the histopathological features of the classic and granulomatous types of the disease .