Poiklodermatous MF ( stage 4B)- Case.pptx

Poiklodermatous MF ( stage 4B)

1. Case presentation DR BILAWAL MUBARAK

2. History 65 years old male known case of HTN and DM , resident of Gambat presented to skin department CHK with complains of Generalized skin Rash for 9 years Progressive darkening of skin for 1 year

3. HOPC According to my patient he was in his usual state of health almost 9 years back when he developed rash on his thighs and buttocks initially then on shoulders. He described rash as ring like lesions which were red in color, itchy and somewhat scaly. He went to multiple clinics and took treatment but his condition did not improve.

4. With passage of time these lesions progressed to involve whole body and he experienced burning sensation and discomfort. For the last 1 year he complained of generalized darkening and dryness of whole skin along with severe itching.

5. There was no history of fever, weight loss or night sweats. He denies any immunosuppression or addiction.

6. Systemic review : unremarkable Past medical history : known case of DM and HTN which are well controlled on oral medications. Drug history : used multiple topical ointments and creams and antihistamines along with antihypertensive and oral hypoglycemics Family history : No chronic illness in the family

7. Personal history: decreased appetite , sleep normal , bladder and bowel habits normal, addiction nil Socioeconomic history : satisfactory

8. GPE Elderly male of average height and built oriented to TPP with vitals BP 140/80 Pulse 82 bpm RR 16 Temp afebrile There was no pallor, jaundice, cyanosis, clubbing, dehydration and pedal edema. Thyroid was not enlarged. Lymph nodes not detected clinically. JVP not raised.

9. Cutaneous examination There is generalised hyperpigmentation and induration of skin with telengectatic erythema on trunk. Multiple hyperpigmented indurated plaques over arms and legs with few areas of sparing. Similar lesions were present on face and scalp. Oral cavity was normal.

10. Systemic examination Unremarkable

11. Differentials? Poiklodermatous / Erythrodermic Mycosis Fungoides Sezary syndrome

12. Investigations HB 12.6 WBC 8.5 PLT 233 CRP 4.5 UCEs and LFTs were normal Serum albumin was 3.2 Viral markers were non reactive

13. Histopathology Sections examined from skin biopsy show scattered atypical lymphocytic infiltrate in the superficial dermis. These atypical cells show nuclear irregularity with perinuclear halo. Foci of epidermotropism are also seen. The IHC markers were performed and showed: CD3: diffuse positive in atypical lymphocytes CD20: negative in atypical lymphocytes CD4>CD8 ratio: 3:1 IMF was done on fresh tissue and showed completely panel negativity.

14. PET CT Pleural based solitary FDG avid lesion in anterior right hemithorax as noted. No evidence of abnormal FDG uptake in dermal tissues .

15. Peripheral film No sezary cells detected

16. Final diagnosis? Poiklodermatous MF ( stage 4B)

17. Management Patient was diagnosed 4 months back at ISD Karachi and he was receiving phototherapy in the form of NB UVB. 36 sessions were done but there was no improvement. Heam oncologist was taken on board and he advised systemic therapy with Methotrexate along with local phototherapy. Tab methotrexate with the dose of 15mg was advised weekly with follow up after 2 weeks.

18. He further received 2 sessions of phototherapy making a total of 38 sessions along with oral methotrexate for 1 month. But there was no much improvement and upon subsequent follow up dose of methotrexate was increased to 20mg. Phototherapy was stopped after discussion with faculty.

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