A case of chronic myelogenous leukemia cutis: a rare presentation.

Sir,

Cutaneous infiltration of leukemias is possible in all types of leukemias in their clinical course. Leukemia cutis can be a rare cause of cutaneous eruptions, which can be mistaken for some other inflammatory skin lesions.

A 70-year-old male patient presented with nonspecific abdominal discomfort and multiple papular and nodular skin lesions all over the body since the preceding 6 months. On examination, the patient was found to have moderate pallor with both cervical and axillary lymph node enlargement; also, multiple cutaneous nodules of variable sizes were seen all over the body [Figure 1]. Per abdominal examination revealed hepatosplenomegaly. The provisional clinical diagnosis was cutaneous metastasis of unknown primary site.

Figure 1

Clinically, patient showing cutaneous nodules on the chest wall and left axillary lymphadenopathy

Investigations done were as follows:

Hematological: Hb: 7.8 gm%; TLC (Total Leucocyte Count): 4.22 lakhs/μL, (DLC (Differential Leucocyte Count): Blasts, 2%; promyelocytes, 8%; myelocytes, 48%; metamyelocytes, 12%; band forms, 3%; polymorphs, 15%; eosinophils, 7%; basophils, 2%; NRBCs(Nucleated Red Blood Cells) : 3/ 100 WBCs (White Blood Cells); platelets, 1.8 lakhs/cu. mm.

Aspiration cytology smears from cutaneous nodule on anterior chest wall revealed variable mixture of mature and immature cells of granulocytic series which were positive for myeloperoxidase [Figure 2]. Lymph node aspiration revealed all types of myeloid cells along with mature lymphocytes. Histopathological sections from skin nodules showed diffuse infiltration of leukemic cells in the dermis, mostly perivascular and periadnexal.

Figure 2

FNAC smears from cutaneous nodule show cells of granulocytic series positive for myeloperoxidase (×100)

Hematological investigations were not advised by the clinician prior to fine-needle aspiration cytology (FNAC) and histopathology of skin nodules. Hence with suspicion of some hematological malignancy, complete blood count and peripheral smears were done and the diagnosis of Chronic myelogenous leukemia (CML) was arrived at. Considering the FNAC and histopathology findings, the diagnosis made was CML cutis.

We sent the case for second opinion to TATA Hospital. Their opinion was that the skin was involved, as evidenced by the presence of chronic myeloproliferative disorder with excess of eosinophils; however, cytogenetic analysis was necessary in this case.

The incidence of leukemia cutis is not known since prospective studies have not been performed.[1] Recent studies have analyzed the clinico-pathological features of specific cutaneous manifestation of myelogenous leukemia in a large number of patients.[2] Leukemia cutis was seen frequently as the cause of lesions in patients with CML and CLL (Chronic lymphoid leukemia).[3] The mean age for the skin eruptions in CML has been found to be 60.6 years.[2]

The patient presented with abdominal discomfort, multiple nodular skin lesions and cervical and axillary lymphadenopathy. These papules and nodules were commonly seen on anterior chest wall, back, face and legs.[145] The cytology of CML cutis lesions showed variable mixtures of mature and immature cells of granulocytic series.[2] Histopathology of leukemia cutis revealed diffuse infiltration of leukemic cells in dermis, predominantly perivascular and periadnexal infiltrates.[25] Leukemia cutis is associated with very poor prognosis; most patients (85%) die within 4 months after appearance of skin metastasis.[5]