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C. Mitteldorf, M. Tronnier, H. Merz, H.A. Haenssle, H.P. Bertsch, M.P. Schön, K.M. Kaune, Insect bite‐like reactions in a patient with B‐cell chronic lymphocytic leukaemia: fluorescence in situ hybridization analysis revealed neoplastic B cells within the skin infiltrate, British Journal of Dermatology, Volume 167, Issue 4, 1 October 2012, Pages 944–946, https://doi.org/10.1111/j.1365-2133.2012.10966.x
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Funding sources: none.
Conflicts of interest: none declared.
Madam, A 71‐year‐old female patient developed itching red papulovesicular eruptions on the head and upper trunk (Fig. 1a,b), with no history of prior insect bites. Five months later, the patient was diagnosed with chronic lymphocytic leukaemia (CLL) of B‐cell type (B‐CLL; stage: Binet A) with TP53 (previously p53) deletion and trisomy 12 as detected by fluorescence in situ hybridization (FISH) in the peripheral blood. Following the diagnosis of CLL, a skin eruption was biopsied and the specimen was fixed in formalin for histological examination according to standard protocols. Immunohistochemistry was performed to assess expression of CD79a, CD23, CD5, CD3, CD4 and CD8. For T‐cell receptor (TCR) and immunoglobulin heavy chain (IgH) gene rearrangement analysis DNA was extracted from paraffin‐embedded tissue of lesional skin and peripheral blood. Both samples were investigated using two independent approaches as described.1
Histological examination of the skin lesions revealed focal epidermal spongiosis, oedema within the papillary dermis and a superficial and deep perivascular and interstitial lymphocytic infiltrate (Fig. 1c). Many admixed eosinophils were found. Interestingly, a prominent follicular infiltrate with typical features of follicular mucinosis, highlighted with Alcian–periodic acid‐Schiff (PAS) staining (Fig. 1c, inset) was found. No bacteria, fungi or Demodex folliculorum were detected in the follicular unit in serial sections with Alcian–PAS staining. Immunohistochemically, the infiltrate was predominantly composed of CD3‐positive T lymphocytes (about 80%; CD4 : CD8=5 : 1; Fig. 1d) with only a few scattered CD20‐positive B lymphocytes (approximately 20%; Fig. 1e) coexpressing CD5 and CD23. B cells were mostly located around the deeper vessels and showed focal follicular epitheliotropism (Fig. 1e). Molecular genetic findings revealed a clonal immunoglobulin gene rearrangement in the skin lesions. The same clonal rearrangement was detectable in the peripheral blood of the patient. In contrast, the TCR rearrangement of the skin lesion was polyclonal.
