Early morphea simulating patch-stage mycosis fungoides

Morphoea presenting histopathologically as mycosis fungoides: an illustrative series of four cases

AIMS

There have been exceptional reports of morphoea presenting with epidermal changes overlapping histopathologically with cutaneous T cell lymphoma of the mycosis fungoides type (MF). This phenomenon gives rise to an ambiguous clinicopathological scenario in which distinguishing these conditions may be challenging. The aim of this study is to characterise the clinical, histopathological and molecular findings of this phenomenon through a case series.

METHODS AND RESULTS

Four patients with classical clinical presentation of morphoea but unusual histopathology displaying typical findings of morphoea, together with intra-epidermal CD8 positive lymphocytes indistinguishable from MF, were identified. The clinical phenotypes of morphoea were varied, and they all presented early in the active phase of the disease. They all exhibited intra-epidermal lymphocytes with tagging and cytological atypia. Pautrier-like microabscesses were also seen. Using molecular analysis, two cases showed clonal TCR gene rearrangement. Follow-up of all cases has been consistent with classical morphoea.

CONCLUSION

Early morphoea can seldom present with atypical clonal intra-epidermal lymphocytes indistinguishable from MF. The fact that these changes can occur in several different clinical subtypes of morphoea raises the possibility that this could be a pattern of inflammation in early disease more common than currently appreciated.

Generalized early inflammatory morphea mimicking interstitial T-cell lymphoma: A diagnostic pitfall

Early generalized morphea can clinically mimic mycosis fungoides. The microscopic features of early inflammatory morphea may show variable degrees of infiltration and do not have the characteristic dermal collagen sclerosis. We report the case of a 63-year-old female patient who presented with a 2-month history of an asymptomatic skin rash. Physical examination revealed multiple erythematous to dusky patches on the trunk and thighs, resembling the patch stage of mycosis fungoides. Two skin biopsies were performed, both of which showed prominent interstitial lymphoid infiltration in the reticular dermis without dermal sclerosis. Small lymphocyte exocytosis and lining along the dermal-epidermal junction were observed focally in the epidermis. Small clusters of plasma cells and eosinophils were observed in perivascular areas. Although no predominant clonality was found for CD4 and CD8 stains, 50% loss of CD5 antigen and 90% loss of CD7 antigen expression were apparent in immunohistochemical studies. Subsequent blood tests showed a normal blood cell count and positive human T-lymphotropic virus Type 1 antibodies. The overall findings suggested interstitial mycosis fungoides or early adult T-cell lymphoma-leukemia. The patient refused aggressive treatment, and 3 months later, she presented with indurated plaques from the previous rash. A repeat biopsy revealed the typical features of morphea. This report discussed the pitfalls in the clinical and histopathological diagnosis of early generalized inflammatory morphea that both clinicians and pathologists should consider.

Small-sized shiny sclerotic plaques: Think early morphea

Morphea is a rare fibrosing disorder of the skin and underlying tissues. To date, the size of morphea has not been adequately discussed. Here, we report two cases of small-sized superficial circumscribed morphea. Both cases clinically revealed single circumscribed, round to oval area of shiny sclerotic plaque at distal extremities. There are several options for the treatment of superficial circumscribed morphea, such as topical corticosteroid and phototherapy. The early recognition of small-sized morphea enables appropriate diagnosis and follow-up, leading to improve disease prognosis.

Vestibulovaginal Sclerosis Versus Lichen Sclerosus

To determine if vestibulovaginal sclerosis and lichen sclerosus (LS) are 2 distinct entities. Biopsies obtained from the vagina or vulvar vestibule that contained abnormal subepithelial collagen were reviewed. Cases were categorized either as LS or vestibulovaginal sclerosis based on presence or absence of basal layer degeneration and lymphocytic infiltrate. Clinical data collected included examination findings, biopsy site and indication, previous vulvovaginal surgery, medications at time of biopsy, vulvar LS, treatment, and response. There were 15 cases with a mean age of 62 yr (range: 32-86 yr); 12 (80%) specimens were from vestibule and 3 from vagina. Nine cases were categorized as LS because of lymphocytic infiltrate in combination with basal layer degeneration, of these 8 had LS elsewhere on vulvar skin. Six cases were classified as vestibulovaginal sclerosis and had an absent or sparse lymphocytic infiltrate and essentially normal epithelium; none of these had vulvar LS. While vestibulovaginal sclerosis and lichen sclerosus are distinguishable clinically and histopathologically, further studies are needed to determine if vestibulovaginal sclerosis is a subset of LS or a different condition.

Early morphea simulating patch-stage mycosis fungoides in two cases

Morphea is a skin disorder characterized by thickening of dermis and subcutaneous tissues and loss of adnexal structures. In the early inflammatory stage of morphea, diagnostic histological findings are absent and this may lead to confusion with other inflammatory dermatoses such as mycosis fungoides (MF). We report two cases of early stage morphea mimicking patchstage of MF. Histopathologic examination of biopsies obtained early in the disease course revealed lymphocytic epidermotropism arranged in small pautrier-like collections as well as linear arrangements in dermal- epidermal junction. Additional biopsies were performed which revealed replacement of subcutaneous fat with closely packed thick collagen bundles under eccrine glands. This report points toward the fact that early stage morphea can simulate MF. Therefore additional evaluation is sometimes required for definite diagnosis.

Defining the mimics and clinico-histological diagnosis criteria for mycosis fungoides to minimize misdiagnosis

Background

Mycosis fungoides (MF) is a significant diagnostic challenge; it has various differential diagnosis especially at an early stage. Our aim was to describe mimics of MF clinically and histologically, and to define significant diagnostic criteria of the disease.

Methods

This was a retro-prospective cohort of 370 patients in whom the diagnosis of MF was suspected clinically.

Results

MF was histologically confirmed in 15.4% of cases and rejected in 84.5%. Other identified histologically diagnosis were eczema, psoriasis; nonspecific dermatitis, lichen, lupus; pseudolymphoma, parapsoriasis and toxidermia. 4 patients with palmoplantar MF were wrongly treated as eczema, and 10 patients with psoriasiform MF were initially treated as psoriasis. We also described the clinical, histological and immunohistochemistry diagnostic criteria for distinguishing MF from benign dermatosis.

Conclusions

Misdiagnosis of MF was a real problem for this study, because it shared common clinical and histological characteristics with other inflammatory diseases like eczema and psoriasis. Therefore, defining significant clinico-histological diagnosis criteria of MF would be of great help and would increase the accuracy of the diagnosis.