Large-Cell Transformed Mycosis Fungoides Coexisting with Mycosis Fungoides Bullosa: A Case Report and Review of the Literature

Intraocular Metastasis of Large T-cell Lymphoma Transformed from Mycosis Fungoides

PURPOSE

To describe a rare case of intraocular lymphoma that metastasized from cutaneous mycosis fungoides and transformed to large cell T cell lymphoma resulting in vitreoretinal pathology.

METHODS

Retrospective case report.

RESULTS

A 57-year-old male presented with 3 months of blurred vision in the right eye. He reported only a medical history of psoriasis. Examination revealed keratic precipitates and dense vitritis in the right eye. He was taken for a diagnostic vitrectomy. Histopathology showed that atypical lymphoid cells and flow cytometry were consistent with transformed large cell T-cell lymphoma. During follow-up, pre- and inner retinal lesions were noted throughout the posterior pole. Histopathology of the psoriatic lesions was consistent with mycosis fungoides. He was initiated on systemic and intravitreal methotrexate with improvement in vision.

CONCLUSIONS

Ocular involvement in metastatic transformed T-cell lymphoma is extremely rare but can be present with vitritis and retinal deposits. Our patient responded well to intravitreal methotrexate therapy.

A Case of Vesicular Mycosis Fungoides

A 44-year-old male presented with 7 months history of nonpruritic round oozing plaques on the extremities and red papules on the trunk. The lesions were resistant to topical and oral steroid prescribed at the other local clinics. Histopathological examination showed parakeratosis with acanthosis and rete ridge elongation as well as spongiotic intraepidermal blisters and dense dermal infiltration of small to medium sized atypical lymphoid cells. Immunohistochemical analysis revealed the lymphocyte infiltrate to be predominantly CD4⁺ T cells, with CD4/CD8 ratio to be greater than 10:1. Infiltration of large cells that were CD30⁺ were also noted. This histopathologic findings are consistent with vesicular mycosis fungoides (MF). He was prescribed with narrow-band ultraviolet B twice per week and topical steroid, combined with interferon-α injection for 5 weeks, and his skin lesions significantly faded and were flattened. Vesicular MF is associated with poor prognosis, but our patient was able to show benign course of disease thanks to timely diagnosis. One must consider vesicular MF as a differential for recalcitrant eczematous lesions.

[Mycosis fungoides bullosa: A rare clinical presentation]

INTRODUCTION

Mycosis fungoides (MF) is the most common form of cutaneous lymphoma and usually manifests as erythematous and scaly patches or plaques. Its phenotypic or histologic presentation can be heterogeneous. Herein we report a very rare form of MF bullosa.

PATIENTS AND METHODS

A 73-year-old man presented with a 4-month history of erythematous, scaly and itchy plaques on the trunk, as well as blistering lesions present for 2 months and which appeared on the trunk and lower limbs, both on patches of MF and on apparently healthy skin. Histopathology confirmed the diagnosis of bullous mycosis fungoides. Gene rearrangement of TCR showed a monoclonal profile in the skin. The hypothesis of bullous pemphigoid was ruled out by additional exams. Our patient was successively treated with combined interferon, bexarotene and methotrexate, followed by vorinostat, resulting in partial remission.

DISCUSSION

Cases of bullous MF are very rare. In the literature, the clinical presentation is heterogeneous, with tense or flaccid bullae that can occur on unaffected skin or on erythematous plaques. The bullae generally appear after the plaques. The histologic blister site may be subepidermal or, more rarely, intra-epidermal. The exact mechanism of blister formation is not clear. Its treatment is poorly codified but follows the usual treatment of MF in its classical form.

CONCLUSION

Bullous MF is a very rare entity that can mimic autoimmune blistering disease, and this diagnosis must therefore be ruled out.