Leukemia Cutis As the Initial Manifestation of Chronic Lymphocytic Leukemia Progression

Abstract

Chronic lymphocytic leukemia (CLL) is a malignant proliferation of monoclonal mature B-cells in peripheral blood. Leukemia cells can commonly spread from the blood to other sites such as the lymph nodes, liver, and spleen. However, contrary to T-cell lymphomas that can involve the skin, CLL metastasis to the skin is unusual and is rarely the first manifestation of systemic disease. When leukemia cells invade the skin, it is termed leukemia cutis. Furthermore, multiple skin morphologies can be present in leukemia cutis making diagnosis challenging. Likewise, it can be mistaken for other common etiologies such as drug or substance allergy, infection, and scabies, among others. We herein present a case of CLL with leukemia cutis as the initial manifestation of systemic disease. The initial punch biopsy results were non-specific for inflammatory changes, but a subsequent biopsy revealed findings confirming leukemia cutis. This case not only demonstrates that identifying malignant skin manifestations in a timely manner and treating them is essential, as it improves the quality of life and survival, but also demonstrates that leukemia cutis can be a dynamic disease where multiple biopsies may be needed to confirm the diagnosis, as histopathology can change over time.

Keywords: atypical rash; chronic lymphocytic leukemia (cll); leukemia cutis; non-hodgkin’s lymphoma b-cell; rash cutaneous lesions.

Figure 1. Multiple skin papules’ presentation at six months

(A) Right upper extremity with two papules. (B) Close-up of the right-hand papules. (C) Papules on the right hand from another perspective. (D) Right lower extremities with multiple patches.

Figure 2. Skin leukemia cutis presentation at 12 months

(A) Bilateral arms with multiple pink and brown papules and macules with a left-sided patch. (B) Magnified left arm.

Figure 3. Histology of punch skin biopsy

H&E magnified 10x: (a) Uninvolved epidermis; (b) Narrow area of the papillary dermis uninvolved by an infiltrate (Grenz zone); (c) Diffuse dense dermal lymphohistiocytic infiltrate.