Letters to the Editor
1229
Table 1 Diagnosis and associated OCT features Patient/Diagnosis (biopsy verified)
OCT features
1/Tumour stage MF
Homogenous wavy-shaped formation of the superficial skin. The fringe is clearly delineated by a hyperreflective border
2/Tumour stage MF
A sharply demarcated hyperreflective formation extending from epidermis to the deeper part of the dermis
3/Plaque stage MF
Normal architecture of the skin disrupted. Not possible to identify the dermo-epidermal junction (DEJ). Hyperreflective homogenous appearance of the dermis. Normal vessels not visible
4/Lymphomatoid papulosis
Clear delineation between papule, normal epidermis and dermis. The border is a thickened hyperreflective band
5/Lymphomatoid papulosis
Delineation between papule and normal epidermis and dermis is evident. The border is a thickened hyperreflective band. Normal vessels not visible in the lesion
group.8 The study depicted a patch stage MF with a striking elongated dark dermal structure. Although the findings differ significantly from our results the elongated structure may represent splitting of the dermal layer. OCT appears to identify a striking morphology in some CTCL lesions not seen in other skin tumours 4,9 thus indicating conventional OCT as a potential tool for non-invasive studies of cutaneous lymphomas. However, discrimination between superficial inflammatory skin diseases and early MF stages may potentially constitute a diagnostic challenge.10 Although there is a lack of OCT studies evaluating different CTCL’s at baseline we speculate that OCT imaging offers utility in quantifying and monitoring epidermal and dermal responses to treatment without relying on an array of biopsies. Additional studies including more patients and various cutaneous lymphomas are warranted to identify the diagnostic accuracy of our findings.
6 Liu TY, Ibrahim M, Bittencourt M, Sepah YJ, Do DV, Nguyen QD. Retinal optical coherence tomography manifestations of intraocular lymphoma. J Ophthalmic Inflamm Infect 2012; 2: 215–218. 7 Jawed SI, Myskowski PL, Horwitz S, Moskowitz A, Querfeld C. Primary cutaneous T-cell lymphoma (mycosis fungoides and Sezary syndrome): part I. Diagnosis: clinical and histopathologic features and new molecular and biologic markers. J Am Acad Dermatol 2014; 70: 205–216. 8 Christian RH, Hansen I, Stamp M, Jemec GB. Imaging cutaneous T-cell lymphoma with optical coherence tomography. Case Rep Dermatol 2012; 4: 139–143. 9 Boone MA, Norrenberg S, Jemec GB, Del MV. High-definition optical coherence tomography imaging of melanocytic lesions: a pilot study. Arch Dermatol Res 2014; 306: 11–26. 10 Boone M, Norrenberg S, Jemec G, Del MV. High-definition optical coherence tomography: adapted algorithmic method for pattern analysis of inflammatory skin diseases: a pilot study. Arch Dermatol Res 2013; 305: 283–297. DOI: 10.1111/jdv.13157
H.C. Ring,1,* A.A. Hussain,2 G.B. Jemec,1 R. Gniadecki,3 L.M. Gjerdrum,4 M. Mogensen3 1
Department of Dermatology, Roskilde Hospital, University of Copenhagen, Roskilde, Denmark, 2Department of Dermatology, Gentofte Hospital, University of Copenhagen, Gentofte, Denmark, 3Department of Dermatology, Bispebjerg Hospital, 4Department of Pathology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark *Correspondence: H.C. Ring. E-mail: [email protected]
References 1 Burg G, Kempf W, Cozzio A et al. WHO/EORTC classification of cutaneous lymphomas 2005: histological and molecular aspects. J Cutan Pathol 2005; 32: 647–674. 2 Wilcox RA. Cutaneous T-cell lymphoma: 2014 update on diagnosis, riskstratification, and management. Am J Hematol 2014; 89: 837–851. 3 Elmer KB, George RM. Cutaneous T-cell lymphoma presenting as benign dermatoses. Am Fam Physician 1999; 59: 2809–2813. 4 Mogensen M, Thrane L, Jorgensen TM, Andersen PE, Jemec GB. OCT imaging of skin cancer and other dermatological diseases. J Biophotonics 2009; 2: 442–451. 5 Forooghian F, Merkur AB, White VA, Shen D, Chan CC. Highdefinition optical coherence tomography features of primary vitreoretinal lymphoma. Ophthalmic Surg Lasers Imaging 2011;42 Online: e97–e99.
JEADV 2016, 30, 1195–1252
IgG/IgA pemphigus representing pemphigus vegetans caused by low titres of IgG and IgA antibodies to desmoglein 3 and IgA antibodies to desmocollin 3 Editor A 50-year-old Japanese man presented with 3-week history of erosive pustules with pruritus on the left foot in February 2013. The patient suffered from Eisenmenger’s syndrome. The patient was administered with valacyclovir for tentative diagnosis of herpes simplex at a local clinic for 2 weeks. However, because the skin lesions were intractable, the patient was referred to us and was admitted to our hospital for a more extensive examination.
© 2015 European Academy of Dermatology and Venereology
Letters to the Editor
1230
(a)
(b)
Figure 1 Clinical features on admission. (a) Skin lesion on the left foot. (b) Verrucous lesion on the oral mucosa.
On admission, the pustules and erosions spread to the plantar and dorsal regions of the left foot (Fig. 1a). He also presented with oral verrucous plaques (Fig. 1b). Laboratory findings (normal values are in square brackets) showed a normal white blood cell count (7.8 9 103/lL, [4.0–8.5 9 103]) with lymphopenia (13%, [27–46%]) and eosinophilia (17%, [1–6%]) as well as elevated C-reactive protein (1.46 mg/dL [
1229
Table 1 Diagnosis and associated OCT features Patient/Diagnosis (biopsy verified)
OCT features
1/Tumour stage MF
Homogenous wavy-shaped formation of the superficial skin. The fringe is clearly delineated by a hyperreflective border
2/Tumour stage MF
A sharply demarcated hyperreflective formation extending from epidermis to the deeper part of the dermis
3/Plaque stage MF
Normal architecture of the skin disrupted. Not possible to identify the dermo-epidermal junction (DEJ). Hyperreflective homogenous appearance of the dermis. Normal vessels not visible
4/Lymphomatoid papulosis
Clear delineation between papule, normal epidermis and dermis. The border is a thickened hyperreflective band
5/Lymphomatoid papulosis
Delineation between papule and normal epidermis and dermis is evident. The border is a thickened hyperreflective band. Normal vessels not visible in the lesion
group.8 The study depicted a patch stage MF with a striking elongated dark dermal structure. Although the findings differ significantly from our results the elongated structure may represent splitting of the dermal layer. OCT appears to identify a striking morphology in some CTCL lesions not seen in other skin tumours 4,9 thus indicating conventional OCT as a potential tool for non-invasive studies of cutaneous lymphomas. However, discrimination between superficial inflammatory skin diseases and early MF stages may potentially constitute a diagnostic challenge.10 Although there is a lack of OCT studies evaluating different CTCL’s at baseline we speculate that OCT imaging offers utility in quantifying and monitoring epidermal and dermal responses to treatment without relying on an array of biopsies. Additional studies including more patients and various cutaneous lymphomas are warranted to identify the diagnostic accuracy of our findings.
6 Liu TY, Ibrahim M, Bittencourt M, Sepah YJ, Do DV, Nguyen QD. Retinal optical coherence tomography manifestations of intraocular lymphoma. J Ophthalmic Inflamm Infect 2012; 2: 215–218. 7 Jawed SI, Myskowski PL, Horwitz S, Moskowitz A, Querfeld C. Primary cutaneous T-cell lymphoma (mycosis fungoides and Sezary syndrome): part I. Diagnosis: clinical and histopathologic features and new molecular and biologic markers. J Am Acad Dermatol 2014; 70: 205–216. 8 Christian RH, Hansen I, Stamp M, Jemec GB. Imaging cutaneous T-cell lymphoma with optical coherence tomography. Case Rep Dermatol 2012; 4: 139–143. 9 Boone MA, Norrenberg S, Jemec GB, Del MV. High-definition optical coherence tomography imaging of melanocytic lesions: a pilot study. Arch Dermatol Res 2014; 306: 11–26. 10 Boone M, Norrenberg S, Jemec G, Del MV. High-definition optical coherence tomography: adapted algorithmic method for pattern analysis of inflammatory skin diseases: a pilot study. Arch Dermatol Res 2013; 305: 283–297. DOI: 10.1111/jdv.13157
H.C. Ring,1,* A.A. Hussain,2 G.B. Jemec,1 R. Gniadecki,3 L.M. Gjerdrum,4 M. Mogensen3 1
Department of Dermatology, Roskilde Hospital, University of Copenhagen, Roskilde, Denmark, 2Department of Dermatology, Gentofte Hospital, University of Copenhagen, Gentofte, Denmark, 3Department of Dermatology, Bispebjerg Hospital, 4Department of Pathology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark *Correspondence: H.C. Ring. E-mail: [email protected]
References 1 Burg G, Kempf W, Cozzio A et al. WHO/EORTC classification of cutaneous lymphomas 2005: histological and molecular aspects. J Cutan Pathol 2005; 32: 647–674. 2 Wilcox RA. Cutaneous T-cell lymphoma: 2014 update on diagnosis, riskstratification, and management. Am J Hematol 2014; 89: 837–851. 3 Elmer KB, George RM. Cutaneous T-cell lymphoma presenting as benign dermatoses. Am Fam Physician 1999; 59: 2809–2813. 4 Mogensen M, Thrane L, Jorgensen TM, Andersen PE, Jemec GB. OCT imaging of skin cancer and other dermatological diseases. J Biophotonics 2009; 2: 442–451. 5 Forooghian F, Merkur AB, White VA, Shen D, Chan CC. Highdefinition optical coherence tomography features of primary vitreoretinal lymphoma. Ophthalmic Surg Lasers Imaging 2011;42 Online: e97–e99.
JEADV 2016, 30, 1195–1252
IgG/IgA pemphigus representing pemphigus vegetans caused by low titres of IgG and IgA antibodies to desmoglein 3 and IgA antibodies to desmocollin 3 Editor A 50-year-old Japanese man presented with 3-week history of erosive pustules with pruritus on the left foot in February 2013. The patient suffered from Eisenmenger’s syndrome. The patient was administered with valacyclovir for tentative diagnosis of herpes simplex at a local clinic for 2 weeks. However, because the skin lesions were intractable, the patient was referred to us and was admitted to our hospital for a more extensive examination.
© 2015 European Academy of Dermatology and Venereology
Letters to the Editor
1230
(a)
(b)
Figure 1 Clinical features on admission. (a) Skin lesion on the left foot. (b) Verrucous lesion on the oral mucosa.
On admission, the pustules and erosions spread to the plantar and dorsal regions of the left foot (Fig. 1a). He also presented with oral verrucous plaques (Fig. 1b). Laboratory findings (normal values are in square brackets) showed a normal white blood cell count (7.8 9 103/lL, [4.0–8.5 9 103]) with lymphopenia (13%, [27–46%]) and eosinophilia (17%, [1–6%]) as well as elevated C-reactive protein (1.46 mg/dL [
