Cutaneous manifestations in leukemia patients

Diagnostic approach to leukemia cutis : A differential diagnostic step-by-step algorithm

OBJECTIVES

Leukemia cutis is a conflicting term to describe neoplastic hematopoietic infiltrates in the skin. Cutaneous myeloid or lymphoid proliferations often present a serious differential diagnostic challenge for pathologists.

METHODS

This review aims to outline the confusion associated with the term leukemia cutis and discuss in detail the foremost common differential diagnoses in daily practice. The review is based on a summary of the relevant literature as well as on the authors' experience.

RESULTS

It addresses precursor cell myeloid and lymphoid tumors that are strictly considered true leukemia cutis but also more mature neoplasms, including some recently described mature extramedullary myeloid proliferations. Finally, a practical, comprehensive stepwise approach combining traditional immunohistochemical marker panels, novel lineage- or mutational-specific markers, and other ancillary tests is suggested to reach an entity-specific diagnosis.

CONCLUSION

The proper combination of ancillary techniques can help the pathologist to provide an accurate diagnosis of these challenging skin lesions.

Organomegalies as a predictive indicator of leukemia cutis in patients with acute myeloid leukemia

BACKGROUND

Leukemia cutis (LC) is an extramedullary acute myeloid leukemia (AML) infiltrate. No previous study has described the clinical characteristics and outcomes of Thai patients diagnosed with AML with LC.

MATERIALS AND METHODS

We conducted a 7-year retrospective case-control study on Thai AML patients at Siriraj Hospital from November 2013 to July 2020. Patients were divided into LC and non-LC groups. Initial clinical presentations and laboratory findings were examined to identify LC-associated factors. Overall survival (OS) and relapse-free survival (RFS) were assessed. Pathological tissues underwent re-evaluation to validate the LC diagnoses.

RESULTS

The study included 159 patients in a 2:1 ratio (106 non-LC and 53 LC). The LC group had a mean ± SD age of 54.3 ± 15.5 years; females were predominant. Three-fifths of the LC patients had intermediate-risk cytogenetics; 20.4% had an adverse risk, and 10.2% had a favorable risk. Most were classified as AML-M4 and AML-M5. Leukemic nodules were the primary finding in 58.5% of the cases, mainly on the legs. In the multivariate analysis of predictive factors associated with LC, organomegalies, specifically hepatomegaly, and lymphadenopathy, remained significant factors associated with LC [OR 4.45 (95%CI 1.20, 16.50); p = 0.026 and OR 5.48 (95%CI 1.65, 18.20); p = 0.005], respectively. The LC group demonstrated a significantly reduced OS (log-rank test p = 0.002) (median OS of 8.6 months vs. 32.4 months). RFS was considerably lower in the LC group (log-rank test p = 0.001) (median duration of 10.3 months vs. 24.4 months in the non-LC).

CONCLUSIONS

AML patients who developed LC tended to experience notably poorer prognoses. Therefore, it is imperative to consider aggressive treatment options for such individuals. The presence of organomegalies in AML patients serves as a strong predictor of the possible occurrence of LC when accompanied by skin lesions.

Leukemia Cutis-The Current View on Pathogenesis, Diagnosis, and Treatment

Leukemia cutis (LC) is defined as the leukemic infiltration of the epidermis, the dermis, and the subcutaneous tissue. Leukemia cutis may follow or occur simultaneously with the diagnosis of systemic leukemia. However, cutaneous lesions are occasionally diagnosed as the primary manifestation of leukemia. Leukemic skin infiltrations demonstrate considerable variation regarding a number of changes, distribution, and morphology. The highest incidence of LC is observed in chronic lymphocytic leukemia, monocytic and myelomonocytic acute myeloid leukemia, and T-cell lineage leukemia. Although the pathogenic mechanism of the invasion of leukemic cells into the skin is not well understood, chemokine receptors and adhesion molecules as well as the genetic characteristics of leukemia are thought to play a role. Leukemic skin lesions may be localized or disseminated and may occur alone or in combination on any site of the skin, most frequently in the trunk and extremities. The most common clinical presentations of leukemia cutis are papules, nodules, macules, plaques, and ulcers. In most patients, the complete or partial resolution of cutaneous infiltrations occurs simultaneously with hematologic remission. However, in patients with resistant disease or recurrent skin infiltration, local radiotherapy can be used. This review presents recent data on the pathogenesis, diagnosis, and treatment of leukemic skin involvement in different types of leukemia.

Dermatological manifestations of hematologic neoplasms. Part I: secondary specific skin lesions

Cutaneous manifestations occur during the course of hematologic malignancies and precede, follow, or are late events in relation to the diagnosis. They result from paraneoplastic phenomena, tumor infiltrations, and immunosuppression resulting from the hematologic neoplasia itself or its treatment. The dermatologist must be aware of these conditions, which can help both in the diagnosis of the underlying disease and in the reduction of patient morbidity. This review (part I) addresses skin lesions associated with direct infiltration by systemic hematologic malignancies.

Leukaemia Cutis: Clinical Features and Outcomes of 56 Patients

Leukaemia is a malignant neoplasm of the haematopoietic system. Cutaneous manifestations of leukaemia are called leukaemia cutis, and are regarded as a sign of poorer prognosis and shorter survival time. A single-institution retrospective review was performed of medical records of patients diagnosed with leukaemia cutis in the dermatology department of Seoul St Mary’s Hospital between January 2012 and April 2021. Fifty-six cases with cutaneous leukaemic involvement and underlying haematological malignancy were included (40 acute myelogenous leukaemia, 8 acute lymphoblastic leukaemia, 3 chronic myeloid leukaemia, 2 chronic lymphocytic leukaemia, and 3 myelodysplastic syndrome). Male-female ratio 1.9:1, mean age at diagnosis 45.8 years. Plaques (28%) and papules (27%) were the most common skin lesions, followed by patches (18%) and nodules (16%). Mean time from diagnosis of leukaemia to development of leukaemia cutis was 12.3 months. Forty-six patients (84%) died during the 7-year follow-up; mean time from diagnosis of leukaemia cutis to death was 5.4 months. The results suggest that leukaemia cutis is associated with poor outcomes in patients with leukaemia. Comprehensive skin examination of these patients may help diagnose leukaemia cutis early, enabling prompt treatment.

Leukaemia cutis for clinicians, a literature review

Leukaemia cutis (LC) describes infiltration of the skin by leukaemia cells, resulting in clinically identifiable cutaneous lesions. LC has a wide range of clinical manifestations, which can make it difficult to distinguish LC from other skin changes. In a group of patients, LC can be the first manifestation of leukaemia, therefore skin biopsy is crucial for the diagnosis. In this mini review, we discuss various types of leukaemia most frequently represented in leukaemia cutis, in both children and adults and skin changes in multiple myeloma, focusing on the clinical presentation of LC and prognosis in patients.

CPX-351 (Vyxeos®) can cause severe rash in acute myeloid leukemia-A case report

CPX-351, a promising new agent for patients with treatment-related and secondary acute myeloid leukemia can lead to a severe whole-body rash. Although severe side effects are rare, treatment should be carefully monitored at specialized centers.

The skin and soft tissue infections in hematological patients

PURPOSE OF REVIEW

Skin and soft tissue infections (SSTIs) in patients with hematological malignancies are frequent, but dedicated epidemiological studies are limited. The aim of this review is to provide updated description of the main etiological agents, differential diagnosis, and treatment.

RECENT FINDINGS

In addition to common causes of bacterial skin infections in any kind of patients, such as streptococci and staphylococci (the letter frequently resistant to methicillin), Pseudomonas aeruginosa is a frequent agent in patients with hematological malignancies, with high virulence and typical infection presenting as ecthyma gangrenosum. Among fungi, fusariosis is the mold infection most frequently associated with skin lesions, although other molds and yeasts (including Candida tropicalis) should be also considered. External infections associated with central venous catheters are frequent in the hematological setting, and in addition to staphylococci, Gram-negative bacteria, fungi, and even rapid growing nontuberculous mycobacteria should be considered. Immunodeficiency might either blunt the typical inflammatory response and make sign or symptoms less evident, or predispose the patients to rapid progression of skin infection to subcutaneous tissues or dissemination.

SUMMARY

SSTIs in hematology patients can be caused by various infectious agents resulting in similar clinical presentation. Rapid and accurate diagnosis is fundamental in order to reduce morbidity and mortality.

Acute myeloid leukemia with adult atopic dermatitis as first manifestation: A case report

RATIONALE

Atopic dermatitis (AD) is a chronic recurrent dermatitis with profound itching, which could be the first manifestation of acute myeloid leukemia (AML).

PATIENT CONCERNS

A 53-year-old Chinese man suffered a 6-month history of systemic symmetrical dermatitis, accompanied with profound itching. The patient was diagnosed as "eczema" in several hospitals, and the effects of antihistamine and topical steroid creams were poor. Nocturnal sleep was seriously affected by aggravating pruritus. Laboratorial examination was compatible with AML-M4.

DIAGNOSES

AML-M4 with AD as first manifestation.

INTERVENTIONS

IA regimen (ayninen and cytarabine) were used in induction chemotherapy. However, the patient did not achieve complete remission, and although his rash had improved, he still experienced severely general body itching. On the seventh day of chemotherapy, the patient entered the period of granulocyte deficiency with infection.

OUTCOMES

The patient died due to septic shock after chemotherapy.

LESSONS

The case strengthens the awareness of AML with AD as first manifestation and raises oncological vigilance in patients with AD refractory.

Leukemia Cutis – A Case Report

Leukemia cutis is a specific skin lesion which is characterized by diffuse infiltration of neoplastic cells and can occur in all types of leukemia. Leukemia cutis can have varied cutaneous presentations such as papules, macules, nodules, plaques and ulcers. We report a case of 52-year-old woman who presented with erythematous macules and papules over her trunk, thighs and upper arms. A skin punch biopsy showed monomorphic, perivascular and periadnexal infiltration by the cells positive for CD45, CD15, CD68 and lysozyme. According to the subsequent bone marrow biopsy and immunophenotypic analysis of peripheral blood cells, the diagnosis of acute monocytic leukemia (FAB AML-M5b) was made. In our case, the first clinical sign suggestive of the diagnosis of leukemia was the presence of erythematous macules and papules. Therefore, we believe that leukemia cutis should be taken into consideration in the differential diagnosis of maculopapular rush on the trunk, upper arms and leg

Skin Infections

Cutaneous infections are common in immunocompromised patients. Neutropenia predisposes patients to fungal, bacterial and viral infections. Antibacterial antifungal and antiviral prophylaxis have caused a significant reduction in some of these infections.

There are two main types of cutaneous infections : primary cutaneous infections and cutaneous manifestations of a disseminated infection. In the latter, skin lesions may be the window to disseminated bloodstream infection and the first and only evidence of a disseminated life threatening infection.

The diagnosis may be at your fingertips; therefore a thorough skin exam is the clue. However, it’s also important to know the characteristic lesions associated with different infections. It will help expedite diagnosis so appropriate treatment is initiated promptly in neutropenic patients, which can be lifesaving.

In a retrospective study of 43 neutropenic febrile patients with cutaneous lesions, fungal infections were the most frequent, and nodular lesions on the lower extremities were the most prevalent (Naorungroj and Aiempanakit, J Am Acad Dermatol 74:AB166, 2016).

Skin biopsy for pathological study and culture remains the gold standard and should be obtained early to confirm the suspected diagnosis. In these immunocompromised patients the inflammatory response is altered by either the primary disease or its treatment. Therefore, routine pathogens may present in an atypical fashion, with diminished or absent induration, erythema, or pustulation in response to bacterial resulting cutaneous infection without typical cellulitis (Urabe, Clin Infect Dis 39:S53–S55, 2004). Skin lesions are evaluated not only by morphology, but also in the context of the clinical setting and biopsy result. The skin biopsy is inexpensive, relatively noninvasive and without contraindication, and may avoid the need for more invasive procedures such an open lung biopsy (Grossman, et al., Cutaneous manifestations of infection in the immunocompromised host. Springer Science+Business Media, LLC, New York, 2012).

In addition to antimicrobial therapy, surgery should not be postponed in the face of progressive skin and soft tissue infection in this population (Brzozowski and Ross, J Hand Surg Br 22:679–680, 1997).