Mantle cell lymphoma presenting with exaggerated skin reaction to insect bites

Mantle Cell Lymphoma and Exaggerated Mosquito Bite Reactions: A New Perspective on Treatment Options

Mantle cell lymphoma (MCL) can, in a few reported cases, create an exaggerated mosquito bite response, leading to numerous bullae and significant edema. The phenomenon is further complicated by the observance of a concurrent Epstein-Barr virus (EBV) reactivation. The current literature provides general information on treatment that most practitioners would consider when attempting to treat an arthropod hypersensitivity reaction, such as topical or systemic corticosteroids. However, no information has been published to date that details a preventive and steroid-sparing approach to treating this phenomenon, without simultaneously treating the MCL. MCL can be indolent in nature and does not always require prompt treatment. The purpose of this case report is to discuss the successful treatment of a rare disorder with a steroid-sparing regimen. The steroid-sparing regimen used consisted of oral doxycycline 100mg twice daily, cetirizine 20mg once daily, and valacyclovir 1g daily, which resulted in sustained reduction in bullous eruptions.

Eosinophilic Dermatosis of Hematologic Malignancy: Emerging Evidence for the Role of Insect Bites-A Retrospective Clinico-Pathological Study of 35 Cases

Background/Objectives: Eosinophilic dermatosis of hematologic malignancy (EDHM) is a rare cutaneous disorder associated with various hematologic malignancies, most commonly chronic lymphocytic leukemia. Detailed clinicopathologic studies of EDHM are lacking and the pathogenesis remains enigmatic. Initially thought to be a hypersensitivity reaction to insect stings, subsequent reports have challenged this understanding. The prognostic implications of EDHM remain unclear. Methods: A retrospective clinicopathologic study was performed on patients diagnosed with EDHM. Hematologic and dermatologic data were reviewed. Histologic specimens were re-evaluated and lesions were classified into acute/subacute, fully developed, and chronic/regressing. Results: The study included 35 patients. In 80% of these patients, EDHM was diagnosed after the hematologic disorder. Approximately 45% of the cohort experienced hematologic disease progression or relapse, while 65% required therapeutic intervention during the course of their hematologic disease. In total, 15/19 CLL patients had non-mutated IgHV, a marker of a more aggressive hematologic disease course. Dermatologic lesion morphology was heterogeneous, with most lesions occurring on exposed areas, and a significant 94% of patients demonstrated lesion seasonality. Histopathologic findings were consistent with features typically associated with insect bites. In addition, examination of lesions at different chronological stages revealed substantial similarities with Wells syndrome. Conclusions: Our findings support the potential role of insect bites in triggering EDHM in the context of adaptive immune dysfunction. EDHM may be associated with a more aggressive disease course or may be a marker of disease progression. The observed co-occurrence of features typical of Wells syndrome in EDHM patients suggests that these conditions are part of a spectrum of disorders that vary in clinical expression.

Eosinophilic dermatosis of hematologic malignancy in patients with chronic lymphocytic leukemia/non-Hodgkin's B lymphoma: a single center prospective clinico-pathological study

Background

The pathogenesis of eosinophilic dermatosis of hematologic malignancy (EDHM) is poorly understood. Previously thought to be a hypersensitivity reaction to insect bites, immune dysregulation and cytokine imbalance are now thought to be responsible. Its prognostic significance is unclear.

Objective

To describe the clinical, pathological and immunological findings in a series of oncohematological patients with EDHM.

Methods

An observational prospective cohort study of oncohematological patients receiving a diagnosis of EDHM between April 2017 and December 2018.

Results

A total of 15 patients with EDHM (10 females and 5 males) were identified among 422 oncohematological patients. Disease presentation varied from firm erythematous papules to more polymorphic presentations. The lesions were most prevalent on the exposed sites, 8/15 patients recalled an insect bite. Lesion seasonality was reported in 13/15 patients. IgE levels were elevated in six patients, circulating IL-4 and IL-5 were within a normal range. Twelve out of 15 patients developed skin manifestations after chemotherapy. The infiltrate could be eosinophil-rich or lymphocytic-rich. Interestingly, the histopathologic findings were in accordance with arthropod bites.

Conclusion

A role for insect bites in EDHM is supported by our findings. EDHM may be related to aggressive hematologic disease.

Clinicopathologic study of mantle cell lymphoma with epstein-barr virus infection: A case series and literature review

Background

Mantle cell lymphoma (MCL) with Epstein–Barr virus (EBV) infection is rarely reported. The objective of this study was to analyze the prevalence and clinicopathological features of MCL with EBV infection in the largest series thus far.

Methods

After screening 138 cases of MCL, we identified eight cases of MCL with EBV infection.

Results

Most of them (7/8) had non-neoplastic bystander cells with positivity for EBV and no expression of latent membrane protein 1 (LMP1) and EBV nuclear antigen 2 (EBNA2). The cases of MCL with EBER positivity did not have abnormal immune function or other lymphomas. Moreover, their histopathological morphology was indicative of classical MCL. Cases of MCL with EBER positivity exhibited statistically significant differences in lactate dehydrogenase, anemia status, and MCL international prognostic index grouping (P=0.008, P=0.02, P=0.001, and P=0.011, respectively). The differences between the two groups in age, sex ratio, clinical manifestations, and immunohistochemical phenotypes were not statistically significant.

Conclusions

The incidence of MCL with EBV infection was low (5.8%). Clinicopathologically, cases of MCL with EBER positivity were similar to their EBV-negative counterparts. Our findings revealed that most cells infected by EBV in MCL are background cells rather than tumor cells. This is inconsistent with data from previous studies, indicating that tumor cells in MCL may not be prone to EBV infection.

What lies beneath: Cutaneous involvement of mantle cell lymphoma underlying an insect-bite-like reaction

Mantle cell lymphoma (MCL) is an uncommon subtype of mature B-cell non-Hodgkin lymphoma characterized by specific morphologic, immunophenotypic, and genetic characteristics, namely the t(11;14)(q13;q32) chromosomal translocation with resultant cyclin D1 overexpression. MCL has a generally aggressive course and is often widely disseminated at the time of diagnosis. Skin involvement is exceedingly rare and is seldom the first manifestation of MCL. We present a case of MCL in an 84-year-old man with cutaneous involvement as the first manifestation, discovered incidentally after biopsy of a persistent nodule believed to be an insect bite. This case not only serves to raise awareness of the possibility of MCL presenting in the skin but also to point out that MCL can have lesions with both an insect-bite-like reaction and a deeper dermal MCL infiltrate.