Skin Findings

Question 1

Malignant cells directly deposited into skin:

Cutaneous ___ cell lymphoma
Cutaneous ___ cell lymphoma
Malignant cells originate in the ___
- Most common is ___ ____
It is usually ___ and affects older ___, - ___ > ____ affected
- Large __ ___ and plaques on __ __ areas
- ____ can involve lymph nodes and blood

• Path shows ____, __ ___and mostly infiltrate is CD___+ T cells with ___ nuclei

Treatment goal is improve appearance and symptoms, prevent progression

Topicals: steroids, nitrogen mustard, chemotherapy

Orals: systemic retinoids, methotrexate

Radiation: UV light, electron beam radiation

IV Chemotherapy

Answer 1

Malignant cells directly deposited into skin:

Cutaneous T cell lymphoma
Cutaneous B cell lymphoma
Malignant cells originate in the SKIN
- Most common is MYCOSIS FUNGOIDES
It is usually INDOLENT and affects older MEN, - BLACK > WHITE affected
- Large ATROPHIC PATCHES and plaques on CLOTHING COVERED areas
- RARELY can involve lymph nodes and blood

• Path shows EPIDERMOTROPISM, PAUTRIER MICROABSCESSE and mostly infiltrate is CD4+ T cells with CEREBRI nuclei

Question 2

__ ___:
Malignant cells migrate from the bone marrow to skin

__ ___:
Malignant cells migrate from solid organ to skin

Answer 2

Leukemia cutis
Malignant cells migrate from the bone marrow to skin

Cutaneous metastases
Malignant cells migrate from solid organ to skin

Question 3

Skin as paraneoplastic manifestation:

Sweet Syndrome
AKA Acute febrile ____ dermatosis
- Abrupt onset of ____ edematous papules and plaques along with ___ and sometimes a ____
~20% associated with __ __.

• Associated with__ leukemia and ___ syndrome
• Easily confused with ____
• Treatment of underlying illness leads to improvement in skin and fever
• Rapid response to systemic steroids or other anti-neutrophil meds like colchicine, dapsone, or potassium iodide
• *Dermatomyositis**
• Inflammation of proximal ___ ___ muscles plus characteristic skin changes/rash
• Up to 40% of patients have underlying ___
• Most common is ___ and ___ but can see with __ and ___
• Look for____ as above + elevated ___ __ and ____
• Muscle biopsy shows inflammatory infiltrate
• MRI of muscle shows hyperintensity on T2 weighted imaging
• Need malignancy screening for first 2 years
• Treat with steroids and steroid-sparing immunosuppressant medications

Answer 3

Skin as paraneoplastic manifestation:

Sweet Syndrome
AKA Acute febrile neutrophilic dermatosis
- Abrupt onset of PAINFUL edematous papules and plaques along with FEVER and sometimes a LEUKOCYTOSIS
~20% associated with lymphoproliferative malignancy

• Associated with myeloid leukemia and myelodysplastic syndrome
• Easily confused with infection
• Treatment of underlying illness leads to improvement in skin and fever
• Rapid response to systemic steroids or other anti-neutrophil meds like colchicine, dapsone, or potassium iodide
• *Dermatomyositis**
• Inflammation of proximal limb girdle muscles plus characteristic skin changes/rash
• Up to 40% of patients have underlying malignancy
• Most common is ovarian and lung but can see with leukemia and lymphoma
• Look for RASH as above + elevated CREATINE KINASE and ALDOLASE
• Muscle biopsy shows inflammatory infiltrate
• MRI of muscle shows hyperintensity on T2 weighted imaging
• Need malignancy screening for first 2 years
• Treat with steroids and steroid-sparing immunosuppressant medications

Question 4

**Skin reaction from treatment of malignancy

1. Bleomycin -**
   ____
   - Flagellate ___ on torso and proximal limbs
   - Unique to bleomycin
   Testable side effect

2. Cytotoxic chemotherapy
- __-___ syndrome
AKA palmar plantar erythrodysesthesia
- Seen with ___ chemotherapy and __ ___ ___.
- Well-demarcated erythema, pain, fissuring, and ____ of palms and soles
- Treated with potent topical __ and ___ of hands and feet during chemo infusion

___ __ - an abnormal loss of hair during the first phase (anagen) of the hair’s growth cycle.

3. Stem cell or bone marrow transplant
___ __ ___ disease
Host cells are __ and replaced by donor ___.
New donor cells ____ host’s tissues within the first 100 days post-transplant

Acute GVHD: ___ + __ __ + ___ (RBD)
Rash is widespread and involves __ and __.

Answer 4

**Skin reaction from treatment of malignancy

1. Bleomycin -**
   hyperpigmentation
   - Flagellated hyperpigmentation on torso and proximal limbs
   - Unique to bleomycin
   Testable side effect

2. Cytotoxic chemotherapy
- hand-foot syndrome
AKA palmar plantar erythrodysesthesia
- Seen with cytotoxic chemotherapy and tyrosine kinase inhibitors.
- Well-demarcated erythema, pain, fissuring, and peeling of palms and soles
- Treated with potent topical steroids and cooling of hands and feet during chemo infusion

Anagen effluvium - an abnormal loss of hair during the first phase (anagen) of the hair’s growth cycle.

3. Stem cell or bone marrow transplant
graft vs host disease
Host cells are depleted and replaced by donor lymphocytes
New donor cells attack host’s tissues within the first 100 days post-transplant

Acute GVHD: rash + elevated bilirubin + diarrhea (RBD)
Rash is widespread and involves palms and soles.

Question 5

Skin complications from immune system dysfunction

1. Parasitic infections
Crusted ___
- Severe infestation with sarcoptes ___ mite
- Disrupted immune system unable to control spread of mites
- Thick ___ crusted ___ covering skin
- Biopsy shows hundreds of ___ on slide
- Requires oral anti-parasitic agent like ___.

• *2. Fungal infections**
• higher risk: __ and ___ patients due to impaired __-____ immune response.
• Aspergillosis
• Common in ____.
• Highest risk: __ and __ patients due to impaired ____ immune response
• Most deep fungal infections do not have skin manifestations, usually pulmonary

Treat serious infections with ___ or ____.
- Second most common fungal infection after ____.
- 5-10% of patients with invasive aspergillosis have __ ___.
Multiple ____/____ indurated plaques
Can develop into ____ which become ___.
Treat with ___.

• Candidiasis
  Oral thrush – most common opportunistic infection
  Gray-white ____ on membranes that ____ when scraped
  Disseminated candidiasis
  Highest risk: __ and ___ patients
  Fever, GI bleed, pulmonary distress, meningitis
  Erythematous __ which progress to ___, pustules and ulcerations

- Fusariosis
Relatively common in ____ patients
___ is involved in 70% of infections
Diagnosis easily made from skin biopsy
Patients often exposed from contaminated __ __.

2. Viral infections
Disseminated __ __
Classic __ ___ affects a single dermatome
Disseminated zoster presents with >20 lesions outside the primary dermatome
In immunocompromised can also involve lungs and CNS and be fatal
Risk for motor nerve neuropathy as well

3. Bacterial infections
   G+ infection
   G- infection
   Fever + new skin lesion  Must rule out infection!
   Skin cultures are frequently negative
   Pay attention to skin breakdown or indwelling devices

Highly deadly bacteria:
Staph aureus (GPC)
Pseudomonas aeruginosa (GNR)
Serratia marascens (GNR)

Ecthyma Gangrenosum - Solitary ____ lesion in ___ area or extremity several centimeters in diameter
Central ____
Caused primarily by ___

Answer 5

Skin complications from immune system dysfunction

1. Parasitic infections
Crusted scabies
- Severe infestation with sarcoptes scabies mite
- Disrupted immune system unable to control spread of mites
- Thick keratotic crusted plaques covering skin
- Biopsy shows hundreds of mites on slide
- Requires oral anti-parasitic agent like ivermectin.

• *2. Fungal infections**
• higher risk: leuemia and lymphoma patients due to impaired cell-mediated immune response.
• Aspergillosis
• Common in immunocompromised.
• Highest risk: leukemia and lymphoma patients due to impaired cell mediated immune response
• Most deep fungal infections do not have skin manifestations, usually pulmonary

Treat serious infections with ampho b or voriconazole.
- Second most common fungal infection after candida.
- 5-10% of patients with invasive aspergillosis have skin manifestations.
Multiple red/violacous indurated plaques
Can develop into blisters which become necrotic
Treat with ampho

• Candidiasis
  Oral thrush – most common opportunistic infection
  Gray-white plaques on membranes that bleed when scraped
  Disseminated candidiasis
  Highest risk: leukemia and lymphoma patients
  Fever, GI bleed, pulmonary distress, meningitis
  Erythematous macules which progress to papules, pustules and ulcerations
• Fusariosis
  Relatively common in neutropenic patients
  Skin is involved in 70% of infections
  Diagnosis easily made from skin biopsy
  Patients often exposed from contaminated hospital water

2. Viral infections
Disseminated herpes zoster
Classic herpes affects a single dermatome
Disseminated zoster presents with >20 lesions outside the primary dermatome
In immunocompromised can also involve lungs and CNS and be fatal
Risk for motor nerve neuropathy as well

3. Bacterial infections
   G+ infection
   G- infection
   Fever + new skin lesion  Must rule out infection!
   Skin cultures are frequently negative
   Pay attention to skin breakdown or indwelling devices

Highly deadly bacteria:
Staph aureus (GPC)
Pseudomonas aeruginosa (GNR)
Serratia marascens (GNR)

Ecthyma Gangrenosum - Solitary painful lesion in inguinal area or extremity several centimeters in diameter
Central ulceration
Caused primarily by pseudomonas