A 63-year-old woman was referred to the Department of Dermatology of the Complejo Hospitalario de Granada, Granada, Spain, in 2016 with painful erythematous desquamative nodules and papules of three weeks' duration. She had a history of stage I infiltrating ductal carcinoma of the breast, unilinear myelodysplastic syndrome with granulocytic involvement, chronic neutropaenia and a diagnosis of T cell (cluster of differentiation [CD]8 + ) large granular lymphocyte (LGL) leukaemia. Upon examination, the papules were distributed mainly on the forehead and right upper and lower limbs . Some of the lesions were fluctuating and suppurative, while the others were of a solid consistency. The examination also revealed oral aphthae which were causing dysphagia [ Figure 1D]. At referral, the patient was receiving treatment with 50 mg of low-dose cyclosporine on alternate days and 300 μg of granulocyte-colony stimulating factor per week, to which a partial response was noted.Given the suspicion of leukaemia cutis, a biopsy of the lesions was taken. The findings were compatible with a diagnosis of folliculitis, with polymerase chain reaction and direct immunofluorescence tests negative for Mycobacterium tuberculosis and immunoglobulin (Ig) G, IgA, IgM and complement 3 deposits, respectively. Consequently, treatment with 500 mg of cloxacillin every six hours and 15 mg of prednisone per day was initiated; however, there was no evidence of clinical improvement. Successive biopsies indicated systemic vasculitis caused by granulomatosis with polyangiitis. Eventually, nine months after the onset of the symptoms, a final biopsy revealed that the papules represented the cutaneous infiltration of LGL leukaemia [ Figure 2], associated with secondary interstitial granulomatous dermatitis. At the time of writing, the patient was being treated with combined cyclophosphamide, vincristine, doxorubicin and prednisone (CHOP) therapy which resulted in the resolution of her cutaneous symptoms [ Figure 3]. There was no evidence on computed tomography of any systemic progression to other organs.LGL leukaemia is a low-grade lymphoproliferative disorder characterised by monoclonal expansion in the peripheral blood and bone marrow with either an activated cytotoxic T lymphocyte (i.e. CD8 or CD57 + cells) or, less frequently, a natural killer (CD3 -, CD8 -or CD56 + cells) phenotype. 1 Generally, LGLs represent 10-15% of circulating mononuclear cells and are identified morphologically by their large size and rounded or dentate nuclei and abundant cytoplasm with azurophilic granules.2 Clonality has been confirmed by T cell receptor gene letter to the editor Sultan Qaboos University Med J, November 2017, Vol. 17, Iss. 4, pp. e489-490,
A 46-year-old woman with no personal or family history of cancer presented to the Department of Dermatology at the Complejo Hospitalario Universitario de Granada, Granada, Spain, in 2017 with an eczematous plaque in the areola of the left breast. The plaque had developed over the course of the past four years and was associated with stinging, itching and occasional suppuration. She had been previously treated with topical corticosteroids and antibiotics without improvement. A mammogram performed the previous year showed a small benign nodule of 8 x 5 mm in diameter and a simple cyst of 5 mm in diameter in the right breast. There was no evidence of ductal ectasia or alterations at the left retroareolar level l. A physical examination revealed an erythematous-squamous plaque of 4 x 5 cm in diameter on the left breast without infiltration and with effacement of the areola-nipple complex [ Figure 1].No local lymph nodes were palpated. A cutaneous ultrasound showed hyperkeratosis of the epidermis with a hypoechoic area in the dermis with increased vascularisation. A large incisional biopsy confirmed a diagnosis of Paget's disease of the nipple with ductal carcinoma in situ. A quadrantectomy and selective sentinel node biopsy were performed, the latter of which was negative. The patient was subsequently monitored for the next three years without evidence of clinical recurrence. CommentPaget's disease of the breast is characterised by the intraepidermal infiltration of malignant glandular interesting medical image Sultan Qaboos University Med J, November 2017, Vol. 17, Iss. 4, pp. e487-488,
Background Psoriasis is a systemic auto-inflammatory disease that is related to an increased risk of organic and psychological comorbidities. Type D is a stable personality trait in healthy subjects but there is no data regarding its stability in patients with moderate-severe psoriasis. Objectives To assess the stability of type D personality in patients with moderate to severe psoriasis as well as assessing the influence of type D personality on anxiety and depression. Methods Prospective cohort study. Forty psoriasis patients with type D personality and sixty-six patients with psoriasis without type D personality were included in the study. Participants completed the DS14 test and HADS at baseline and four years later. Results At baseline, the prevalence of type D personality was 37.7% and at week 208 it was 27.3%. The stability of type D personality was higher in patients with an incomplete education level and in those who were separated/divorced or windowed. During follow-up, 15% of patients developed type D personality. Male sex, having topical treatment, the presence of previous depression, anxiety, and high levels of negative affectivity at baseline increase the risk of developing type D personality. Study limitations Sample size, psoriasis severity restricted to moderate and severe and all patients being under treatment for psoriasis. Conclusions The presence of type D personality varies over time in psoriasis patients. Therefore, type D personality is possibly more a state than a trait phenomenon, modified by environmental factors. Type D personality is associated with a higher risk of anxiety.
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