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A 67-year-old woman was seen in March 1986 at the Johns Hopkins Dermatology Clinic, Baltimore, with a recurring eruption on the extremities. She had been evaluated in 1982 for a recent history of fatigue and anemia. In January 1985 she noted the appearance of five asymptomatic, erythematous plaques on the extensor aspects of her forearms and lower limbs. She was treated with oral prednisone therapy (20 mg/d) on the presumption that the lesions were vasculitis. The plaques resolved and prednisone therapy was discontinued. In January 1986 the patient noted a recurrence of the eruption on both feet, which was assoicated with discomfort on walking. The lesions persisted despite a one-month trial of oral prednisone therapy (60 mg/d). The patient was then referred for dermatologic evaluation, at which time the lesions had been present for four months.Physical examination revealed discrete, nontender, violaceous, blanching plaques on the lateral and posterior aspects of both feet, extending proximally on the skin overlying the Achilles tendon (Figs 1 and 2). Examination of a biopsy specimen taken from the right heel revealed a dense perivascular and, to a lesser extent, periappendageal infiltrate in the superficial and deep dermis that was composed of mononuclear cells (Figs 3 and 4). A periodic acidSchiff stain was negative. Direct immunofluores¬ cence revealed scattered interstitial deposits of IgM throughout the dermis.Laboratory studies revealed a hemoglobin of 100 g/L and a hematocrit of 0.31. The serum level of IgM was 11.2 g/L (normal, 1.45 ± 1.05 g/L) and an immunoelectrophoretogram contained a peak of restricted mobility. Examination of bone marrow aspirate revealed ringed sideroblasts and a diffuse infiltrate of small lymphocytes.
A 67-year-old woman was seen in March 1986 at the Johns Hopkins Dermatology Clinic, Baltimore, with a recurring eruption on the extremities. She had been evaluated in 1982 for a recent history of fatigue and anemia. In January 1985 she noted the appearance of five asymptomatic, erythematous plaques on the extensor aspects of her forearms and lower limbs. She was treated with oral prednisone therapy (20 mg/d) on the presumption that the lesions were vasculitis. The plaques resolved and prednisone therapy was discontinued. In January 1986 the patient noted a recurrence of the eruption on both feet, which was assoicated with discomfort on walking. The lesions persisted despite a one-month trial of oral prednisone therapy (60 mg/d). The patient was then referred for dermatologic evaluation, at which time the lesions had been present for four months.Physical examination revealed discrete, nontender, violaceous, blanching plaques on the lateral and posterior aspects of both feet, extending proximally on the skin overlying the Achilles tendon (Figs 1 and 2). Examination of a biopsy specimen taken from the right heel revealed a dense perivascular and, to a lesser extent, periappendageal infiltrate in the superficial and deep dermis that was composed of mononuclear cells (Figs 3 and 4). A periodic acidSchiff stain was negative. Direct immunofluores¬ cence revealed scattered interstitial deposits of IgM throughout the dermis.Laboratory studies revealed a hemoglobin of 100 g/L and a hematocrit of 0.31. The serum level of IgM was 11.2 g/L (normal, 1.45 ± 1.05 g/L) and an immunoelectrophoretogram contained a peak of restricted mobility. Examination of bone marrow aspirate revealed ringed sideroblasts and a diffuse infiltrate of small lymphocytes.
A patient with leukemic reticuloendotheliosis ("hairy cell" leukemia) with sideroblastic anemia and an epinephrine-induced platelet-aggregation abnormality is presented. Immunologic membrane marker studies supported a B-lymphocyte origin of the hairy cells. It is hypothesized that a defect in the pluripotent marrow stem cell may be responsible for the hairy cell leukemia and for the intrinsic abnormalities in erythrocytes and platelets.
A 73-year-old heterosexual man developed a high-grade non-Hodgkin's lymphoma at the site of an ileostomy only 2 years after proctectomy for undetermined colitis not cured by previous colectomy. In fact, the early occurrence of this usually very late and rare complication of ileostomy was probably favored by the simultaneous presence of acquired immune deficiency syndrome (AIDS) due to repeated blood transfusions for refractory anemia with excess blasts. The intestinal location of the tumor, its high-grade malignancy and B-cell origin are all features of AIDS-related non-Hodgkin's lymphoma. This case report seems to be one of the rarely identified examples of the cooperation between general predisposing factors and local irritating agents at the origin of a malignant tumor.
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