CASE IS OPEN.  
 
Case is Kind Courtesy of dr.S.Nikulshin (Latvia).  
 
66 y.o., male.  
CLIN STORY: Prior anamnesis of skin psoriasis treated with daivobet.  
Arterial hypertension treated with ACE inhibitor.  
 
Presented to the outpatient clinic on october 27, 2020 with complaints about a round slowly progressing plaque (painless, not itching) on the back below the left scapula (MACRO PHOTO) for 4 months.  
Previously (september 24 2020) prescribed treatment with topical steroids in combination with topical antifungals and antiseptics (isoconazoli nitras/ diflucortoloni valerias combination and Castellani sollution) did not lead to the resolution of the plaque.  
A fungal culture taken 1 month before negative from the plaque and sole skin, but positive for bipolaris spp. from toenails.  
Upon presentation the patient is feeling well, overall physical and mental state does not appear to be altered.  
Lymph nodes are not enlarged.  
ERUPTIONS IN DETAIL:  
1. Large oval relatively well demarcated red plaque consisting of partially confluent towards the centre small papules, erythema between the papules, fine scaling and central yellowish crust approx. the size of 1 palm below the left scapular area, oriented along Blaschko lines. There are maculopapular elements and hypopigmentation around the plaque’s borders. Duration: 4 months. (biopsy specimen 1 from the marginal zone of the plaque)  
2. A group of painless ill defined papules and nodules of various shapes, some of them confluent, with a rose to brownish or orangish hue and mild ill defined erythema, scaling and red follicular dots in between mostly on the proximal ⅔ of the dorsal and radial aspects of the left forearm. Duration: 4 months. (biopsy specimen 2 from the side of a nodule)  
3. Violaceous macule on the dorsal aspect of the right hand proximal to the base of 4th and 5th fingers. Does not appear infiltrated, skin surface looks shiny and atrophic. Presented about 1 year ago with a psoriasiform plaque, treated with daivobet, does not progress. Daivobet discontinued on august 18 2020.  
4. Discovered later. Multiple oval-shaped subcutaneous nodules 2-3 cm in size with normal appearing overlying skin, nontender, connected to the overlying dermis on the lower abdomen and the frontal aspect of the upper leg close to the inguinal area. Appear to be more superficial than a lymph node on palpation. (Not investigated yet, as remained unnoticed on the first visit. USG and excision biopsy planned.)  
Given polymorphous and dubious clinical findings 3mm punch biopsy was performed on the first visit. Treatment was not attempted after biopsy.  
 
HISTO: Heavilly follicolothropic lymphoid infiltrate (T) with minimal surface lymphothropism, admixture of B population and granulocytes (secondary changes).  
Photos HE from both lesions. IH photos from back lesion.  
 
PROPOSAL:  
FOlliculothropic Mycosis fungoides. Any signs of psoriasis.  
IH: CD3+ CD5(-)(LOSS); CD4+; CD8(-); CD30(-).  
 
ThankYouBeeingClose.  

tzankov 2020-11-27 20:22	Nicely documented case of a CD4+ mature T-cell lymphoma, consistent with MF variant.
SergeyN 2020-11-28 12:38	Thank you, Ugnius and Alex, for your help with this case.
ugnius 2020-11-30 09:43	Thanx Both a Lot.