Case for Diagnosis
Indurated Plaque on the Upper Lip of a Patient With Multiple Myeloma
Placa infiltrada en labio superior de paciente con mieloma múltiple
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B, CD20 ×20. gr2.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was an 87-year-old woman with multiple myeloma who was receiving treatment with bendamustine and prednisone. She was seen for a lesion on her upper lip that had first appeared 2 weeks previously, coinciding with the last cycle of chemotherapy. She had previously had painful vesicles on the hard palate and tip of the tongue.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed an indurated erythematous-edematous plaque and crusting vesicles on the left side of the upper lip and an erythematous macule on the nasal septum and left nasal ala (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Histopathology revealed an epidermis with mild acanthosis, spongiosis, and exocytosis in the absence of cytopathic changes. The follicular epithelium contained foci of vacuolar degeneration and solitary apoptotic keratinocytes. A dense lymphoplasmacytic infiltrate with noncaseating granulomas was visible in the dermis (<a class="elsevierStyleCrossRef" href="#fig0005">Figs. 1B-D</a>). Histochemistry did not reveal germs. The lymphoid infiltrate comprised predominantly CD3 cells (<a class="elsevierStyleCrossRef" href="#fig0010">Figs. 2A and B</a>), with CD30<span class="elsevierStyleSup">+</span> cells and no light chain restriction. Immunohistochemistry for herpes simplex virus (HSV) types 1 and 2 was negative. Polymerase chain reaction of the exudate for determination of HSV was negative, although it proved to be positive for HSV-1 in the biopsy specimen.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What is your diagnosis?</span></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Atypical granulomatous herpes simplex infection.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course and Treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">Given the clinical suspicion of HSV infection in an immunosuppressed patient, treatment was started with famciclovir 750<span class="elsevierStyleHsp" style=""></span>mg/d for 14 days. The patient's clinical condition improved, with mild residual erythema remaining.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Cutaneous eruptions caused by HSV-1, HSV-2, and varicella-zoster virus are common. Diagnosis is generally based on the presence of characteristic vesicles. All 3 viruses are histopathologically indistinguishable. The most commonly observed entities are balloon-like basal keratinocytes with multinuclear nuclei, ground glass appearance, and a vacuolated eosinophilic cytoplasm. Secondary acantholysis, epidermal necrosis, ulceration, and leukocytoclastic vasculitis are also observed.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> However, in immunosuppressed patients and patients with cancer and blood diseases in particular, lesions can also present as plaques, papules, nodules, tumors, and ulcers that tend to be chronic. In such cases, therefore, it is common practice to take biopsy specimens,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> and histology findings may be similar to those of benign and malignant lesions, with little or no epidermal involvement. Various findings have been proposed as diagnostic criteria in these patients, including involvement of adnexal structures with a vacuolar interface pattern and periadnexal infiltrate, as well as keratinocytic necrosis, multinucleation, syringotropism, and perineural symptoms.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,3,4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The lesion rarely presents as granulomatous dermatitis. In fact, in a recent review that analyzed the histopathologic characteristics of HSV, this presentation was found in only 1 out of 65 cases studied.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Furthermore, in some series, the presence of atypical lymphocytes has been reported in more than 65% of cases. These cells can express CD30, thus mimicking CD30<span class="elsevierStyleSup">+</span> lymphoproliferative disorders.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> In rare cases, HSV infection leads to a CD56<span class="elsevierStyleSup">+</span> lymphocyte–rich infiltrate, thus mimicking NK/T lymphoma; in other cases it mimics B-cell lymphoma and plasmacytoma. Herpes infection can also mimic inflammatory conditions such as lupus, insect bites and stings, rosacea, erythema multiforme, and linear IgA bullous dermatosis. In these conditions, confirming a diagnosis requires a high degree of suspicion, and performance of immunohistochemistry testing for herpes can help, although its sensitivity is lower in the absence of vesicles, as is the case for polymerase chain reaction.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Furthermore, there have been reports of inflammatory oncotaxis in areas affected by herpesvirus infection in patients with leukemia (especially B-cell chronic lymphocytic leukemia) and neoplastic plasma cell infiltrate in affected areas of patients with myeloma (ruled out in the present case). It was also necessary to differentiate our findings from the Wolf isotopic response, where several types of dermatosis, mainly granulomatous dermatitis, affect an area that had previously been infected by herpesvirus, mainly herpes zoster infection, but that was now healed.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> The latency period of both conditions ranges from a few weeks to years.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> The underlying mechanism of this entity could be a delayed hypersensitivity reaction, since viral DNA is not usually identified and outcome is not affected by antiviral treatment.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical Course and Treatment" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Comment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 7 => array:2 [ "identificador" => "xack262388" "titulo" => "Acknowledgments" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ramos-Rodríguez C, González-López L, García-Arpa M. Placa infiltrada en labio superior de paciente con mieloma múltiple. Actas Dermosifiliogr. 2017;108:61–62.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 789 "Ancho" => 990 "Tamanyo" => 249882 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">B, Hematoxylin-eosin ×4. C, Hematoxylin-eosin ×10. D, Hematoxylin-eosin ×20. gr1.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 415 "Ancho" => 990 "Tamanyo" => 152627 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, CD3 ×4. B, CD20 ×20. gr2.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Histological spectrum of cutaneous herpes infections" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B. Hoyt" 1 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 16 | 7 | 23 |
| 2024 October | 82 | 35 | 117 |
| 2024 September | 73 | 24 | 97 |
| 2024 August | 107 | 46 | 153 |
| 2024 July | 96 | 28 | 124 |
| 2024 June | 106 | 46 | 152 |
| 2024 May | 71 | 38 | 109 |
| 2024 April | 75 | 26 | 101 |
| 2024 March | 75 | 27 | 102 |
| 2024 February | 49 | 37 | 86 |
| 2024 January | 37 | 32 | 69 |
| 2023 December | 47 | 13 | 60 |
| 2023 November | 63 | 34 | 97 |
| 2023 October | 75 | 25 | 100 |
| 2023 September | 63 | 34 | 97 |
| 2023 August | 45 | 18 | 63 |
| 2023 July | 48 | 30 | 78 |
| 2023 June | 50 | 26 | 76 |
| 2023 May | 49 | 23 | 72 |
| 2023 April | 49 | 21 | 70 |
| 2023 March | 65 | 27 | 92 |
| 2023 February | 65 | 28 | 93 |
| 2023 January | 58 | 39 | 97 |
| 2022 December | 62 | 52 | 114 |
| 2022 November | 24 | 22 | 46 |
| 2022 October | 39 | 18 | 57 |
| 2022 September | 37 | 51 | 88 |
| 2022 August | 30 | 46 | 76 |
| 2022 July | 21 | 53 | 74 |
| 2022 June | 22 | 38 | 60 |
| 2022 May | 53 | 32 | 85 |
| 2022 April | 35 | 32 | 67 |
| 2022 March | 43 | 43 | 86 |
| 2022 February | 27 | 25 | 52 |
| 2022 January | 35 | 29 | 64 |
| 2021 December | 38 | 39 | 77 |
| 2021 November | 43 | 47 | 90 |
| 2021 October | 32 | 55 | 87 |
| 2021 September | 31 | 40 | 71 |
| 2021 August | 31 | 42 | 73 |
| 2021 July | 26 | 40 | 66 |
| 2021 June | 24 | 34 | 58 |
| 2021 May | 54 | 41 | 95 |
| 2021 April | 83 | 84 | 167 |
| 2021 March | 64 | 37 | 101 |
| 2021 February | 47 | 39 | 86 |
| 2021 January | 37 | 32 | 69 |
| 2020 December | 25 | 25 | 50 |
| 2020 November | 25 | 22 | 47 |
| 2020 October | 13 | 14 | 27 |
| 2020 September | 33 | 17 | 50 |
| 2020 August | 30 | 29 | 59 |
| 2020 July | 16 | 22 | 38 |
| 2020 June | 38 | 36 | 74 |
| 2020 May | 21 | 12 | 33 |
| 2020 April | 16 | 20 | 36 |
| 2020 March | 29 | 11 | 40 |
| 2020 February | 7 | 0 | 7 |
| 2019 May | 3 | 0 | 3 |
| 2019 April | 1 | 3 | 4 |
| 2018 December | 5 | 2 | 7 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 2 | 0 | 2 |
| 2018 February | 29 | 1 | 30 |
| 2018 January | 39 | 6 | 45 |
| 2017 December | 45 | 13 | 58 |
| 2017 November | 33 | 10 | 43 |
| 2017 October | 24 | 5 | 29 |
| 2017 September | 27 | 1 | 28 |
| 2017 August | 25 | 9 | 34 |
| 2017 July | 20 | 4 | 24 |
| 2017 June | 43 | 8 | 51 |
| 2017 May | 29 | 10 | 39 |
| 2017 April | 26 | 16 | 42 |
| 2017 March | 34 | 23 | 57 |
| 2017 February | 80 | 44 | 124 |
| 2017 January | 62 | 34 | 96 |
| 2016 December | 11 | 18 | 29 |
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