Leonine Facies and Madarosis in a Man With Shortness of Breath

Abstract

A man in his 60s presented as a transfer from an outside hospital. The division of dermatology was consulted for evaluation of lesions on the face, chest, back, and arms that were gradually increasing in size and number over the past year. Physical examination revealed leonine facies with madarosis and an eschar on the nasal dorsum (Figure , A). Red-tobrown dome-shaped papules coalescing into plaques were present on the upper extremities. The lesions were nontender and nonpruritic. Cervical and axillary lymph nodes were palpable. The patient had a muffled voice and reported shortness of breath with exertion. Results of laboratory investigation demonstrated marked leukocytosis with a white blood cell count of 77.5 × 10 3 /uL with 76.5% lymphocytes. No blasts were present on peripheral smear. Computed tomography of the chest, abdomen, and pelvis demonstrated multiple enlarged mediastinal, axillary, subpectoral, abdominopelvic, and inguinal lymph nodes. Small pulmonary nodules were also detected. A punch biopsy was obtained from the right arm (Figure , B, C, and D). Clinical image A Original magnification ×100 B Original magnification ×400 C Cyclin D1 stain D Figure. A, Infiltrative plaques and nodules obscuring normal facial architecture. B and C, Histopathologic images show normal epidermis with dense diffuse dermal lymphoid infiltrate composed of small to medium cells with irregular nuclear contours (hematoxylin-eosin stain). D, Immunohistochemistry shows diffusely positive cyclin D1 staining. WHAT IS YOUR DIAGNOSIS? A. Mantle cell lymphoma B. Folliculotropic mycosis fungoides C. Diffuse large B-cell lymphoma D. Marginal zone lymphoma Quiz at jamacmelookup.com Clinical Review & Education