Letters to the Editor
Ankita Kaushik, Hyacinth P. Pinto, Ramesh M. Bhat, Sukumar D., Srinath M. K. Department of Dermatology, Father Muller Medical College, Mangalore, Karnataka, India Address for correspondence: Dr. Ramesh M. Bhat, Department of Dermatology, Father Muller Medical College, Kankanady, Mangalore - 575 002, Karnataka, India. E‑mail: [email protected]
REFERENCES
4.
5.
6.
tinea versicolor in south Indian patients. Indian J Dermatol 2003;48:83‑6 Morais PM, Cunha MG, Frota MZ. Clinical aspects of patients with P. Versicolor seen at a referral center for tropical dermatology in Manaus, Amazonas, Brasil. An Bras Dermatol 2010;85:797‑803. Rao GS, Kuruvilla M, Kumar P, Vinod V. Clinico‑epidermiological studies on tinea versicolor. Indian J Dermatol Venereol Leprol 2002;68:208‑9. Sunenshine PJ, Schwartz RA, Janniger CK. Tinea versicolor. Int J Dermatol 1998;37:648‑55.
Access this article online Quick Response Code: Website: www.idoj.in
1. 2. 3.
Mayer PA, Preuss J. Pityriasis versicolor: New aspects of an old disease. Hautarzt 2012;63:859‑67. MendezTovar LJ. Pathogenesis of dermatophytosis and tinea versicolor. Clin Dermatol 2010;28:185‑9. Krishnan A, Thapa DM. Morphological and pigmentary variations of
Idiopathic cutaneous pseudolymphoma: An enigma Sir, Pseudolymphoma is not a specific disease but an inflammatory response to known or unknown stimuli that results in a lymphomatous‑appearing picture, mimicking lymphoma but in fact a benign accumulation of inflammatory cells. However, the terminology of pseudolymphoma should be reserved for idiopathic cases where inciting cause is unknown. The enigma stems from the fact that the condition has to be differentiated from cutaneous lymphoma which would change the outcome of the disease. This case presented as a pigmented nodule just above left ala of nose since 2 years resembling a nevus in a middle‑aged male which was asymptomatic [Figure 1]. The patient gave a history of recent increase in size since 2 months with no pain, discharge, and itching. On examination, it was a firm red‑brown nodule, non‑tender with no regional lymph nodes palpable. There was no history of insect bite, trauma, and infection at that site in the past. There was no history of drug ingestion. A wide excision was done; the histopathology was reported as cutaneous pseudolymphoma. At 6‑month follow‑up, patient was asymptomatic. Immunohistochemistry revealed negative CD3, CD10, leucocyte common antigen (LCA), and CD20 panel, which are markers for lymphoma. After ruling out all etiological factors mentioned above and the histological evidence of top heavy dermal, mixed cellular infiltrate, absence of pigmentation and blast cells, with no necrotic areas, it was labeled as idiopathic pseudolymphoma.
224
DOI: 10.4103/2229-5178.131141
Pseudolymphoma, also called as cutaneous lymphoid hyperplasia, is a skin lesion having lymphomatous appearance mimicking lymphoma that results from known or unknown stimulus like insect bites, vaccination, trauma, folliculitis, drugs, jewelry, and contactants.[1,2] This results in accumulation of inflammatory cells that not only mimics lymphoma histologically but clinically as well. Nodular lesions resemble B‑cell lymphomas, whereas plaque forms resemble T‑cell lymphomas. It is essential to differentiate pseudolymphomas from malignant lymphomas, which involves clinical, histological, and immunohistochemistry evidences as even in benign lesions, malignant histological picture may be seen. Pseudolymphomas are classified according to histological components into B‑cell and T‑cell variants. Commonly occurring etiological causes have been tabulated along with salient
Figure 1: Nodular lesion over left ala of nose
Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
Letters to the Editor
b
a a
b
Figure 3: (a) top heavy infiltrate rich in small T lymphocytes with admixed, scattered T and B immunoblasts, histiocytes, and plasma cells. (H and E, ×10) (b) High-power field showing mixed infiltrate of T and B cells, histiocytes, and plasma cells (H and E, ×40)
Table 1: Classification of cutaneous pseudolymphomas c
d
Figure 2: ×40 Immunohistochemistry stains using LCA, CD3, CD10, CD20 antibodies. (a) Leucocyte common antigen shows positivity for lymphocytes indicating predominant lymphocytic lesion (b) CD3 shows positivity for T cells but the larger cells are negative for the stain (c) CD10 shows positivity for B cells (d) CD20 shows Positivity for B cells. The larger cells are negative for the stains
histological features [Table 1]. Cutaneous lymphomas are classified according to EORTC classification.[3] Immunohistochemistry[4] forms the mainstay of differentiation in a rural setup where advanced laboratory techniques are unavailable. Minimum immunohistochemistry for any suspected hematolymphoid lesion is CD10, LCA, CD20, and CD3. CD20 is for B‑cell expression, CD3 for T‑cell expression and T cell germinal center, and CD10 for B‑cell germinal center. In this case, CD3, CD10, LCA, and CD20 were negative, thus suggesting benign nature of the lesion [Figure 2a‑d]. Techniques such as immunophenotyping staining patterns are done to diagnose lymphomas.[5] The diagnosis poses a challenge more to pathologists, as the pattern of mixed infiltrate that includes histiocytes, eosinophils, and plasma cells is significant. Polymorphous infiltrates, lack of atypical lymphocytes, and dominant lymphocytic clones are highly suggestive of pseudolymphomas[6] [Figure 3]. The infiltrate tends to be “top‑heavy,” in pseudolymphomas, whereas in most lymphomas, they are centered in the deep dermis. The LCA also forms a major source of differentiation, as it is negative in pseudolymphomas and strongly positive in lymphomas. In conclusion, pseudolymphomas form a diagnostic challenge in rural medical college hospital with limited resources for advanced investigations. A proper history to rule out etiology, careful histological evaluation along with judicious immunohistochemistry panel suffices, to diagnose pseudolymphomas. In many cases, a proper etiology may not be elicitable leading to labelling these cases idiopathic.[7,8] A follow‑up of at least 5 years is required to rule out risk of cutaneous lymphomas. Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
Cutaneous T‑cell pseudolymphomas
Histology
Idiopathic
Lesion plaque like, histiocytes predominant.
Contact dermatitis
T‑cell histologic pattern with a bandlike infiltrate in the papillary dermis, predominantly of small lymphocytes, with variable epidermotropism
Arthropod bite Nodular scabies Actinic Cutaneous B‑cell pseudolymphomas
Lesion nodular, Top heavy infiltrate, mixed, eosinophils, histiocytes, plasma cells.
Idiopathic
Immunoblastic reaction, blast cell infiltration, necrosis and vascular proliferation in hypersensitivity reactions.
Drug reactions Tattoo induced Post zoster scar
Pigments in intracellular and intercellular areas in tattoo/gold induced lesions
Persistent arthropod bite
Vinod Prabhu, Aslam Shivani, Vishrabdha R. Pawar Department of surgery, Bharati Medical College, Sangli, India Address for correspondence: Dr. Vinod Prabhu Sangli Shreyas, Behind Central Warehouse, Miraj ‑ 416 410, India. E‑mail: [email protected]
REFERENCES 1.
2. 3.
4.
5.
Shtilionova S, Drumeva P, Balabanova M, Krasnaliev I. What is pseudolymphoma and its nature. J IMAB‑Annual Proceeding (Scientific Papers) 2010;16:Book 3. Bergman R. Pseudolymphoma and cutaneous lymphoma: Facts and controversies. Clin Dermatol 2010;28:568‑74. Willemze R, Kerl H, Sterry W, Berti E, Cerroni L, Chimenti S, et al. EORTC classification for primary cutaneous lymphomas: A proposal from the Cutaneous Lymphoma Study Group of the European Organization for Research and Treatment of Cancer. Blood 1997;90:354‑71. Hasan M, Shahid M, Varshney M, Mubeen A, Gaur K. Idiopathic lymphocytoma cutis: A diagnostic dilemma. BMJ Case Rep 2011; bcr1220103662. Bergman R, Khamaysi K, Khamaysi Z, Ben Arie Y. A study of histologic and immunophenotypical staining patterns in cutaneous lymphoid hyperplasia. J Am Acad Dermatol 2011;65:112‑24.
225
Letters to the Editor 6.
7. 8.
Bergman R, Khamaysi Z, Sahar D, Ben‑Arieh Y. Cutaneous lymphoid hyperplasia presenting as a solitary facial nodule: Clinical, histopathological, immunophenotypical, and molecular studies. Arch Dermatol 2006;142:1561‑6. Ploysangam T, Breneman DL, Mutasim DF. Cutaneous pseudolymphomas. J Am Acad Dermatol 1998;38:877‑95. Stephen J, Shwartz RA. Plasma cell predominant Bcell pseudolymphoma. Dermatol Online J 2008;14:12.
Art of publication: The title, abstract, and cover letter Sir, Singh et al. offer excellent advice on how best to select a journal for a paper and how to format the paper and hence that it is most likely to be accepted.[1] However, the paper misses a number of important points when putting together a paper. First, putative authors should give adequate time to writing their abstract. The abstract is generally short in the context of the entire article and yet it is the part that is most likely to be read. Certainly, it is most likely to be read first by the editor who will be deciding whether or not to publish the article. In fact, some editors screen papers by reading the abstract and don’t actually read the paper if they are not sufficiently impressed by the abstract. However, authors typically leave writing their abstract to the last minute when they are often exhausted and short of time. This practice should be turned on its head. Authors should spend a significant amount of time writing the abstract and ensuring that it is of high quality and in the correct format for the journal. Second, there is the issue of the cover letter. Most journals give authors the opportunity to write a cover letter explaining why their article is important and/or topical and/or significant. The cover letter should not just reproduce the abstract-rather it should address the editor directly and explain why the article is right for the journal and its readership. Authors should beware exaggerating the importance of their paper; however, some authors leave the cover letter section blank, and this is to miss out on a great opportunity.
226
Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.131143
Third and finally, there is the issue of the title. Singh et al. are correct to suggest that titles should be both attractive and accurate. However, authors should also give some consideration as to the format of titles that the journal typically publishes. Authors should ask themselves whether titles are in the form of a question, or are descriptive, or are more journalistic in style. Authors should then format their title in the way that the journal typically publishes. In publishing as in life, first impressions count and the best way to make a good first impression in medical publishing is to pay adequate attention to the title, abstract and cover letter.
Kieran Walsh BMJ Learning, BMJ, BMA House, London, UK Address for correspondence: Dr. Kieran Walsh, BMJ Learning, BMA House, Tavistock Square, London WC1H 9JR, UK. E‑mail: [email protected]
REFERENCE 1.
Singh A, Singh S, Mercy P, Singh AK, Singh D, Singh M, et al. Art of publication and selection of journal. Indian Dermatol Online J 2014;5:4‑6.
Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.131144
Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
Copyright of Indian Dermatology Online Journal is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Ankita Kaushik, Hyacinth P. Pinto, Ramesh M. Bhat, Sukumar D., Srinath M. K. Department of Dermatology, Father Muller Medical College, Mangalore, Karnataka, India Address for correspondence: Dr. Ramesh M. Bhat, Department of Dermatology, Father Muller Medical College, Kankanady, Mangalore - 575 002, Karnataka, India. E‑mail: [email protected]
REFERENCES
4.
5.
6.
tinea versicolor in south Indian patients. Indian J Dermatol 2003;48:83‑6 Morais PM, Cunha MG, Frota MZ. Clinical aspects of patients with P. Versicolor seen at a referral center for tropical dermatology in Manaus, Amazonas, Brasil. An Bras Dermatol 2010;85:797‑803. Rao GS, Kuruvilla M, Kumar P, Vinod V. Clinico‑epidermiological studies on tinea versicolor. Indian J Dermatol Venereol Leprol 2002;68:208‑9. Sunenshine PJ, Schwartz RA, Janniger CK. Tinea versicolor. Int J Dermatol 1998;37:648‑55.
Access this article online Quick Response Code: Website: www.idoj.in
1. 2. 3.
Mayer PA, Preuss J. Pityriasis versicolor: New aspects of an old disease. Hautarzt 2012;63:859‑67. MendezTovar LJ. Pathogenesis of dermatophytosis and tinea versicolor. Clin Dermatol 2010;28:185‑9. Krishnan A, Thapa DM. Morphological and pigmentary variations of
Idiopathic cutaneous pseudolymphoma: An enigma Sir, Pseudolymphoma is not a specific disease but an inflammatory response to known or unknown stimuli that results in a lymphomatous‑appearing picture, mimicking lymphoma but in fact a benign accumulation of inflammatory cells. However, the terminology of pseudolymphoma should be reserved for idiopathic cases where inciting cause is unknown. The enigma stems from the fact that the condition has to be differentiated from cutaneous lymphoma which would change the outcome of the disease. This case presented as a pigmented nodule just above left ala of nose since 2 years resembling a nevus in a middle‑aged male which was asymptomatic [Figure 1]. The patient gave a history of recent increase in size since 2 months with no pain, discharge, and itching. On examination, it was a firm red‑brown nodule, non‑tender with no regional lymph nodes palpable. There was no history of insect bite, trauma, and infection at that site in the past. There was no history of drug ingestion. A wide excision was done; the histopathology was reported as cutaneous pseudolymphoma. At 6‑month follow‑up, patient was asymptomatic. Immunohistochemistry revealed negative CD3, CD10, leucocyte common antigen (LCA), and CD20 panel, which are markers for lymphoma. After ruling out all etiological factors mentioned above and the histological evidence of top heavy dermal, mixed cellular infiltrate, absence of pigmentation and blast cells, with no necrotic areas, it was labeled as idiopathic pseudolymphoma.
224
DOI: 10.4103/2229-5178.131141
Pseudolymphoma, also called as cutaneous lymphoid hyperplasia, is a skin lesion having lymphomatous appearance mimicking lymphoma that results from known or unknown stimulus like insect bites, vaccination, trauma, folliculitis, drugs, jewelry, and contactants.[1,2] This results in accumulation of inflammatory cells that not only mimics lymphoma histologically but clinically as well. Nodular lesions resemble B‑cell lymphomas, whereas plaque forms resemble T‑cell lymphomas. It is essential to differentiate pseudolymphomas from malignant lymphomas, which involves clinical, histological, and immunohistochemistry evidences as even in benign lesions, malignant histological picture may be seen. Pseudolymphomas are classified according to histological components into B‑cell and T‑cell variants. Commonly occurring etiological causes have been tabulated along with salient
Figure 1: Nodular lesion over left ala of nose
Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
Letters to the Editor
b
a a
b
Figure 3: (a) top heavy infiltrate rich in small T lymphocytes with admixed, scattered T and B immunoblasts, histiocytes, and plasma cells. (H and E, ×10) (b) High-power field showing mixed infiltrate of T and B cells, histiocytes, and plasma cells (H and E, ×40)
Table 1: Classification of cutaneous pseudolymphomas c
d
Figure 2: ×40 Immunohistochemistry stains using LCA, CD3, CD10, CD20 antibodies. (a) Leucocyte common antigen shows positivity for lymphocytes indicating predominant lymphocytic lesion (b) CD3 shows positivity for T cells but the larger cells are negative for the stain (c) CD10 shows positivity for B cells (d) CD20 shows Positivity for B cells. The larger cells are negative for the stains
histological features [Table 1]. Cutaneous lymphomas are classified according to EORTC classification.[3] Immunohistochemistry[4] forms the mainstay of differentiation in a rural setup where advanced laboratory techniques are unavailable. Minimum immunohistochemistry for any suspected hematolymphoid lesion is CD10, LCA, CD20, and CD3. CD20 is for B‑cell expression, CD3 for T‑cell expression and T cell germinal center, and CD10 for B‑cell germinal center. In this case, CD3, CD10, LCA, and CD20 were negative, thus suggesting benign nature of the lesion [Figure 2a‑d]. Techniques such as immunophenotyping staining patterns are done to diagnose lymphomas.[5] The diagnosis poses a challenge more to pathologists, as the pattern of mixed infiltrate that includes histiocytes, eosinophils, and plasma cells is significant. Polymorphous infiltrates, lack of atypical lymphocytes, and dominant lymphocytic clones are highly suggestive of pseudolymphomas[6] [Figure 3]. The infiltrate tends to be “top‑heavy,” in pseudolymphomas, whereas in most lymphomas, they are centered in the deep dermis. The LCA also forms a major source of differentiation, as it is negative in pseudolymphomas and strongly positive in lymphomas. In conclusion, pseudolymphomas form a diagnostic challenge in rural medical college hospital with limited resources for advanced investigations. A proper history to rule out etiology, careful histological evaluation along with judicious immunohistochemistry panel suffices, to diagnose pseudolymphomas. In many cases, a proper etiology may not be elicitable leading to labelling these cases idiopathic.[7,8] A follow‑up of at least 5 years is required to rule out risk of cutaneous lymphomas. Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
Cutaneous T‑cell pseudolymphomas
Histology
Idiopathic
Lesion plaque like, histiocytes predominant.
Contact dermatitis
T‑cell histologic pattern with a bandlike infiltrate in the papillary dermis, predominantly of small lymphocytes, with variable epidermotropism
Arthropod bite Nodular scabies Actinic Cutaneous B‑cell pseudolymphomas
Lesion nodular, Top heavy infiltrate, mixed, eosinophils, histiocytes, plasma cells.
Idiopathic
Immunoblastic reaction, blast cell infiltration, necrosis and vascular proliferation in hypersensitivity reactions.
Drug reactions Tattoo induced Post zoster scar
Pigments in intracellular and intercellular areas in tattoo/gold induced lesions
Persistent arthropod bite
Vinod Prabhu, Aslam Shivani, Vishrabdha R. Pawar Department of surgery, Bharati Medical College, Sangli, India Address for correspondence: Dr. Vinod Prabhu Sangli Shreyas, Behind Central Warehouse, Miraj ‑ 416 410, India. E‑mail: [email protected]
REFERENCES 1.
2. 3.
4.
5.
Shtilionova S, Drumeva P, Balabanova M, Krasnaliev I. What is pseudolymphoma and its nature. J IMAB‑Annual Proceeding (Scientific Papers) 2010;16:Book 3. Bergman R. Pseudolymphoma and cutaneous lymphoma: Facts and controversies. Clin Dermatol 2010;28:568‑74. Willemze R, Kerl H, Sterry W, Berti E, Cerroni L, Chimenti S, et al. EORTC classification for primary cutaneous lymphomas: A proposal from the Cutaneous Lymphoma Study Group of the European Organization for Research and Treatment of Cancer. Blood 1997;90:354‑71. Hasan M, Shahid M, Varshney M, Mubeen A, Gaur K. Idiopathic lymphocytoma cutis: A diagnostic dilemma. BMJ Case Rep 2011; bcr1220103662. Bergman R, Khamaysi K, Khamaysi Z, Ben Arie Y. A study of histologic and immunophenotypical staining patterns in cutaneous lymphoid hyperplasia. J Am Acad Dermatol 2011;65:112‑24.
225
Letters to the Editor 6.
7. 8.
Bergman R, Khamaysi Z, Sahar D, Ben‑Arieh Y. Cutaneous lymphoid hyperplasia presenting as a solitary facial nodule: Clinical, histopathological, immunophenotypical, and molecular studies. Arch Dermatol 2006;142:1561‑6. Ploysangam T, Breneman DL, Mutasim DF. Cutaneous pseudolymphomas. J Am Acad Dermatol 1998;38:877‑95. Stephen J, Shwartz RA. Plasma cell predominant Bcell pseudolymphoma. Dermatol Online J 2008;14:12.
Art of publication: The title, abstract, and cover letter Sir, Singh et al. offer excellent advice on how best to select a journal for a paper and how to format the paper and hence that it is most likely to be accepted.[1] However, the paper misses a number of important points when putting together a paper. First, putative authors should give adequate time to writing their abstract. The abstract is generally short in the context of the entire article and yet it is the part that is most likely to be read. Certainly, it is most likely to be read first by the editor who will be deciding whether or not to publish the article. In fact, some editors screen papers by reading the abstract and don’t actually read the paper if they are not sufficiently impressed by the abstract. However, authors typically leave writing their abstract to the last minute when they are often exhausted and short of time. This practice should be turned on its head. Authors should spend a significant amount of time writing the abstract and ensuring that it is of high quality and in the correct format for the journal. Second, there is the issue of the cover letter. Most journals give authors the opportunity to write a cover letter explaining why their article is important and/or topical and/or significant. The cover letter should not just reproduce the abstract-rather it should address the editor directly and explain why the article is right for the journal and its readership. Authors should beware exaggerating the importance of their paper; however, some authors leave the cover letter section blank, and this is to miss out on a great opportunity.
226
Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.131143
Third and finally, there is the issue of the title. Singh et al. are correct to suggest that titles should be both attractive and accurate. However, authors should also give some consideration as to the format of titles that the journal typically publishes. Authors should ask themselves whether titles are in the form of a question, or are descriptive, or are more journalistic in style. Authors should then format their title in the way that the journal typically publishes. In publishing as in life, first impressions count and the best way to make a good first impression in medical publishing is to pay adequate attention to the title, abstract and cover letter.
Kieran Walsh BMJ Learning, BMJ, BMA House, London, UK Address for correspondence: Dr. Kieran Walsh, BMJ Learning, BMA House, Tavistock Square, London WC1H 9JR, UK. E‑mail: [email protected]
REFERENCE 1.
Singh A, Singh S, Mercy P, Singh AK, Singh D, Singh M, et al. Art of publication and selection of journal. Indian Dermatol Online J 2014;5:4‑6.
Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.131144
Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
Copyright of Indian Dermatology Online Journal is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
