A 44 y.o. woman from Nigeria comes to the ED with a lesion on her neck.
What is your differential?
Our patient had late stage mycosis fungoides. MF is a cutaneous T cell lymphoma. Ulcerative stages, as in our patient, occur in advanced lymphoma. It accounts for 4% of non Hodgkin lymphoma
Mycosis fungoides has protean manifestations with a premycotic stage that looks like eczema. In the early stages it presents with plaque-like lesions on the skin which can be treated with UV A light. This can progress to skin tumors with ulcer formation. In the final stages T cells may be found in the blood (Sezary syndrome), lymph nodes and viscera.
early stage, plaques
DIFFERENTIAL OF SKIN LESIONS PRESENTING WITH ULCERS
1. Infectious diseases- buruli ulcers, gummas from tertiary syphilis , chancroid, yaws.
H. Ducreyi and treponema pertenue are the bacterial causes of 2/3 of ulcers in children worldwide. A Buruli ulcer is caused by the bacterium mycobacterium ulcers and is common in central Africa.
2 Parasitic diseases- cutaneous leishmaniasis is transmitted through the bite of
Infected females sandflies.
leishmaniasis in Guatemala
3 Autoimmune diseases- Sweet’s disease (acute febrile neutrophilic dermatosis ), bechets, pyoderma gangrenosum.
4 Malignancy- squamous cell ca, mycosis fungoides, breast, head and neck and melanoma cancers.
5 Vascular insufficiency- venous ulcers are usually shallow and on the legs or feet.
Arterial ulcers also appear on the legs and feet but are associated with arterial insufficiency.
venous ulcer
6 Neuropathic disease-leprosy, diabetic ulcers
7 Pressure ulcers - often found on the heel. They can occur with as little of two hours without movement.
8 Excessive scratching can lead to ulcers as well. Prurigo nodularis results in intense itching and skin breakdown from scratching. Strongyloides, mycobacteria and psychiatric disorders. have all been touted as causes.
Treatment of advanced disease is with immune suppression and drugs like mogamulizumab. CCR4 receptors are blocked with this therapy. Our patient was lost to follow up.
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Gunawan H, Utami F, Achdiat P, et al. A unique case of borderline lepromatous leprosy with psoriasis=like lesions all over the body and mycosis fungoides=like lesions on the face. J Clin Tuberc Other Mycobat Dis. 2019 Nov 16;17:100134 doi” 10.1016/j/jctibe/2019/100134
Gonzalez-Beiras , Vall-Mayans M, Gonzalez Esalante A, et al. Yaws osteoperiostitis treated with single dose azithromycin. 2027 May 3;96(5):1039-1041.
Chang P, Meaux, Calderon, et al. Ulcerated cutaneous leishmaniasis. Our Dermatol Online 2015;6(1):92-93.