PMC9676003_01
Clinical manifestations of PNP on the forehead (A), oral mucosa (B), left forearm (C) and genitalia (D).
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Secondly, there were multiple ill-defined, erythematous papules, some coalescing into plaques and overlying with group of erosions and scattered bullae on both upper extremities (Figure 1A-D).
Clinical manifestations of DLE on the right concha (A) and upper back (B); Dermoscopic findings of DLE on the scalp (C).
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Thirdly, there was a well-demarcated, erythematous atrophic plaque with follicular plugging and peripheral hyperpigmentation on the right concha (Figure 2A). Lastly, there were multiple, well-defined, purplish plaques, with overlying whitish scales and few erosions on scalp, face, upper chest, upper back and both lower legs (Figure 2B). Dermoscopic examination revealed thick, whitish and yellowish scales, follicular keratotic plugs, erythematous background with peripheral purplish-brown area on the scalp lesion (Figure 2C).  
Histopathological examination of PNP showing suprabasal separation with lichenoid lymphocytic infiltration (H&E, x10); acantholytic keratinocytes with tombstone appearance (inset, x40).
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Histopathological examination from the forehead revealed suprabasal separation with acantholytic keratinocytes and focal lichenoid lymphocytic infiltration with melanophages (Figure 3) suggestive of paraneoplastic pemphigus (PNP).
Direct immunofluorescence of PNP demonstrating intercellular deposition with IgG (A); perieccrine granular deposition of C3 (B).
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Direct immunofluorescence (DIF) showed intercellular deposition of IgG (Figure 4A) and C3. IgG, IgM and C3 at perieccrine areas (Figure 4B). Indirect immunofluorescence using rat bladder substrate was positive for intercellular deposition as well.
Histopathological examination of hypertrophic DLE showing focal lichenoid, superficial and deep perivascular lymphocytic infiltration with marked epidermal hyperplasia (H&E, x4); perifollicular interface changes with necrotic basal keratinocytes (inset, x40).
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There was also perifollicular interface changes with scattered basal necrotic keratinocytes, compatible with hypertrophic discoid lupus erythematosus (DLE) (Figure 5).   
Computed tomography (CT) scan of chest and whole abdomen demonstrating infiltrative soft-tissue mass surrounding the periaortic and aortocaval regions with extension to involve the right psoas muscle (red arrow).
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To evaluate for associated tumor, computed tomography (CT) scan of the chest and whole abdomen with intravenous contrast media was performed and showed an infiltrative soft-tissue mass surrounding the periaortic and aortocaval regions with extension to involve the right psoas muscle (Figure 6).