Paraneoplastic Erythroderma as a Protean Manifestation of Adenocarcinoma Prostate.

Sir,

Erythroderma (red man syndrome or exfoliative dermatitis) is a rare inflammatory skin disorder which is well characterized by erythema and usually associated with variable proportion of scaling involving 90% of the body surface area (BSA). Erythroderma is primarily caused by psoriasis followed by drug reactions and few malignancies rarely.[1] Prostate cancer (PCa) is the second-most common malignancy and 5th predominant cause of mortality worldwide according to GLOBOCAN database.[2] Erythroderma might provide a sign to detect a possible underlying malignancy in 1% of the elderly age group.[3] Hence, we here present a case of a 80-year-old diabetic male who had presented with erythroderma and was finally diagnosed to have adenocarcinoma of the prostate gland.

Dermatological examination demonstrated generalized scaling and exfoliation involving >90% of the BSA. Pronounced erythema was observed over scalp [Figure 1], palms, and soles. Curdy white plaque was noted on tongue [Figure 2]. Bilateral toenails showed subungual hyperkeratosis and ridging. Bilateral non-tender inguinal lymphadenopathy was present. Lichenified papules and scaly plaques were seen over the extensor surfaces of trunk, upper and lower limbs. Histopathological results of skin biopsy revealed acanthosis, parakeratosis, spongiosis, and lymphocytic exocytosis with lymphocytic infiltrate admixed with pigment-laden macrophages seen around adnexa and blood vessels [Figures 3 and 4]. Few Civatte bodies and neutrophils were also observed.

Figure 1

Pronounced erythema and scaling over scalp

Figure 2

Leukoplakia on tongue

Figure 3

Photomicrograph showing parakeratosis, acanthosis, spongiosis and lymphocytic exocytosis with lymphocytc nfiltrate admixed with melanophages around adnexa and blood vessels (H and E, ×40)

Figure 4

Histological features in higher magnification (H and E, x100)

His routine blood investigation revealed low Hb, elevated total count, high blood sugar, increased blood urea and elevated levels of serum prostate-specific antigen (PSA). Rest of the parameters were within normal limits. Per rectal examination revealed hard tender prostatomegaly. The abnormal values of both average flow rate (4 ml/s) and postvoid residual (20 ml) from uroflowmetry established the diagnosis of PCa. Transrectal ultrasound-guided biopsy showed poorly differentiated anaplastic adenocarcinoma of the prostate with Gleason score (3 + 3) and WHO grade of Group 1 [Figure 5]. Technetium 99m-methyl diphosphonate scanning of the whole body revealed no evidence of bone metastasis. Transurethral resection of the prostate with bilateral orchidectomy was employed with an uneventful postoperative period. The patient was discharged and followed up once every 3 months till reporting.

Figure 5

Prostate biopsy demonstrating poorly differentiated anaplastic prostate adenocarcinoma grade I (H and E, x40 top; H and E, x100 bottom)

Our patient had shown the clinical features of erythroderma along with mild anemia and leukocytosis with eosinophilia.[3] This case report had also established the diagnosis of erythroderma secondary to PCa as paraneoplastic manifestation. Epidemiological information on erythroderma incidence in the Indian subcontinent is deficient. Male gender preponderance is common in the age group between 61 and 70 years. Inflammatory skin disorders secondary to malignancy are reported in 1%–11% of patients. The association of PCa with different paraneoplastic syndromes had been well documented as a rare entity.[4] Out of all the urological malignancies, PCa occupies the position next to renal cell carcinoma. Momm et al. have reported and concluded that PSA is a useful marker as stated in our paper.[5] Erythroderma may occur as a protean manifestation of these paraneoplastic syndromes in an advanced stage of the tumor with poor prognosis.

The pathogenesis of PCa-related erythroderma is thought to be immune mediated. The previous reports had proposed that cellular adhesion molecules (VCAM-1, ICAM-1, E-selectin, and P-selectin) and cytokines (interleukin 1-2-8) to be key players through complex interaction resulting in a higher epidermal turnover.[6] Routine screening of malignancy-related biomarkers is recommended in older individuals of more than 45 years who had no previous history of skin pathology or unexplained dermatological finding like erythroderma.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.