PMC9769073_01
Maculopapular coalescing and symmetric exanthema of the limbs. No blisters or vesicles observed, and negative Nikolsky sign.
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f1
The previously described exanthema evolved with centrifugal, from trunk and back to upper and lower limbs, symmetric and coalescing features; without blisters or vesicles and negative Nikolsky sign (Figure 1).
Dermatosis evolution. Pre-treatment with betamethasone (1A/1B). Post-treatment: 2A/2B (fourth day); 3A/3B (seventh day); 4A/4B (eleventh day).
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f2
On the presumption diagnosis of a DRESS syndrome, the patient started empirical topical betamethasone, with overall good response over a 14-day period, until complete resolution of the dermatosis (Figure 2).
A- Neoplastic cells composed of medium-sized lymphoid cells with irregular and hyperchromatic nuclei and large lymphoid cells with irregular and vesicular nuclei with prominent nucleoli. Numerous mitotic figures are seen (HE, 400x). B- Atypical lymphoid cells positive for CD3 (IHC, anti-CD3 Ab, 400x).
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f3
Histopathologic examination revealed a complete effacement of the nodal architecture by a diffuse infiltrate of medium-sized lymphoid cells with irregular and hyperchromatic nuclei, and large lymphoid cells with irregular and vesicular nuclei with prominent nucleoli (Figure 3A). Immunohistochemistry studies revealed that the atypical lymphoid cells expressed diffusely CD3 (Figure 3B), with partial loss of CD5 and multifocal expression of CD4, CD8, PD-1 and ICOS (CD278).
Staging 18FDG-PET/CT demonstrating bilateral supra- and infradiaphragmatic lymphoproliferative involvement.
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f4
Staging 18fluorodeoxyglucose positron emission tomography combined with computed tomography (18FDG-PET/CT) showed high-grade metabolic lymphoproliferative disease with bilateral supra and infra-diaphragmatic involvement, and likely splenic and Waldeyer-ring involvements (Figure 4).
A- Epidermis with hyperparakeratosis, infiltrating lymphocytes, vacuolar alteration of basilar keratinocytes and dermis with superficial perivascular and interstitial infiltrate of small lymphocytes and histiocytes (HE, 200x). B- Scattered eosinophils in the dermal infiltrate (HE, 400x).
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f5
In the dermis there was a superficial perivascular and interstitial infiltrate, composed of small lymphocytes and histiocytes, with scattered eosinophils (Figures 5A and 5B).