PMC3580916_01
Skin.
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She also noted a general discomfort and brownish discoloration in her left leg during the same period (Figure 1(a)), which was managed by the vascular surgeons as venous insufficiency. On physical examination, she had multiple nodular lesions extending from mid shin to ankle (Figure 1(b)).
Punch biopsy of the left leg.
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The biopsy showed a diffuse dermal infiltrate of large pleomorphic cells, some with plasmacytic differentiation (cells with rounded nuclei, coarser chromatin, and smaller nucleoli) and others with the appearance of immunoblasts (cells with enlarged nuclei, vesicular chromatin, and a single prominent nucleolus) (Figure 2(a)). Immunohistochemistry showed these to be negative for CD20 and stain positive for CD138, Bcl-2, CD45, and CD79a (weak), with a high Ki-67 proliferation index approaching 50% (Figures 2(b) to 2(e)). Staining for Epstein-Barr virus (EBV) by in situ hybridization (EBV EBER-ISH) showed positive nuclear staining (Figure 2(f)).
MRI of the left leg. Subcutaneous nodules and myositis of tibialis anterior are shown on T2 fat-saturated axial view (a) and short T1 inversion recovery (STIR) coronal view (b). After treatment, the changes are resolved (c, d).
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Staging investigation including a magnetic resonance imaging (MRI) of the left leg confirmed the subcutaneous lesions and adjacent myositis of tibialis anterior without any bony involvement (Figures 3(a) and 3(b)). This resulted in a near resolution of the skin nodules and the myositis on the repeat of MRI scan (Figures 3(c) and 3(d)). 
MRI spine. T2 fat-saturated axial view at the initial staging showed a compression fracture of T8 (a) and no other osseous lesions (a, b). Five months later, appearances were suspicious for lymphomatous infiltration with abnormal signal in T11 and T12 vertebral bodies and multilevel compression fractures of thoracic spine (c) and lumbar spine (d).
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MRI of the spine showed the T8 compression fracture with no other suspicious osseous lesions (Figures 4(a) and 4(b)). MRI spine showed multilevel compression fractures at T6, T8, L1, L3, and L5 as well as abnormal marrow signal at T11 and T12 suspicious for lymphomatous infiltration (Figures 4(c) and 4(d)).