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July 2009

On the Trail of a New Killer

Arch Dermatol. 2009;145(7):811-813. doi:10.1001/archdermatol.2009.145

In this issue of the Archives, Weenig et al1 describe 3 patients with clinically presumed psoriasis with nondiagnostic skin biopsies, whose disease, after a long course, eventually evolved into extensive ulcerative indurated plaques culminating in the patients' deaths. None of them had evidence of systemic lymphoma on physical examination or imaging studies, and bone marrow biopsies were negative for disease. Skin biopsies showed epithelial necrosis and exocytosis of T cells expressing the cytotoxic granule components granzyme B and T-cell intracellular antigen 1. These infiltrates were probably composed of cytotoxic T cells with a CD8+ or double-negative (CD4/CD8) phenotype and had no evidence of Epstein-Barr viral (EBV) integration or dominant T-cell clonality. Although dominant T-cell clonality or internal involvement was never proven, the authors1 conclude that these patients probably had aggressive cytotoxic lymphomas (CLs). This extensive ulceronecrotic presentation and a fatal course accompanied by negative results from a systemic workup are indeed common findings in CL.

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