Case History

A 50-year-old female without any comorbidities presented with a history of skin lesions over the face, trunk, and limbs ([Fig.?1]) for 4 months with generalized weakness and weight loss over a period of 2 months. On examination, there were multiple erythematous skin lesions on the face that coalesced to form nodular plaque of varying sizes from 2 mm to 4 cm over the erythematous base with mild scaling and yellowish black crusting. She also had hyperpigmented macules over the trunk and limbs. Other findings were pallor and splenomegaly.

|?Fig. 1?Multiple nodular skin lesions over the face.|

Differential Diagnosis

• Pyoderma gangrenosum

• Vasculitis

• Drug reaction

• Urticaria

• Viral exanthem

• Hidradenitis

• Erythema multiforme

• Erythema nodosum

• Infections due to immunosuppression: cellulitis, herpes zoster, and herpes simplex

Workup

Complete hemogram showed a total leukocyte count of 80,000/mm along with shift to left. Peripheral smear examination showed blasts with increase in myeloid precursors and basophilia. Bone marrow aspirate revealed increased myeloid precursors with the presence of all the stages of maturation (myelocytes, metamyelocytes, and neutrophils). Blasts constituted around 86% of nucleated marrow cells. Karyotyping and fluorescence in situ hybridization showed translocation t(9:22), confirming the diagnosis of chronic myeloid leukemia (CML). Skin biopsy showed diffuse blast cell infiltration in the superficial dermis ([Fig.?2A?D]).

|?Fig. 2?(a) Photomicrograph of bone marrow aspirate showing suppressed erythroid, myeloid, and megakaryocytic series and replaced by blast cells; (b) photomicrograph of bone marrow biopsy showing diffuse sheets of large blast cells; (c) photomicrograph of skin biopsy with dermis showing perivascular and diffuse infiltration by large blast cells; and (d) karyotype of bone marrow analysis showing a Philadelphia chromosome.|

Diagnosis

Based on the above investigations, she was diagnosed as a case of CML in blast crisis with leukemia cutis as an extramedullary deposit. CML in blast crisis has a dismal prognosis with a median survival of 9.4 months. Our patient finally succumbed to death after 4 months of presentation. This case emphasizes the fact that a high degree of suspicion and expertise is important for diagnosing such uncommon presentation of common malignancies. Hence, early diagnosis of such rarer presentations helps in appropriate treatment, which ultimately leads to better chance of survival and reduces the risk of fatality.

Disclaimer

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Conflict of Interest

None declared.

Financial Support and Sponsorship

Nil.

Address for correspondence

|?Fig. 1?Multiple nodular skin lesions over the face.|

|?Fig. 2?(a) Photomicrograph of bone marrow aspirate showing suppressed erythroid, myeloid, and megakaryocytic series and replaced by blast cells; (b) photomicrograph of bone marrow biopsy showing diffuse sheets of large blast cells; (c) photomicrograph of skin biopsy with dermis showing perivascular and diffuse infiltration by large blast cells; and (d) karyotype of bone marrow analysis showing a Philadelphia chromosome.|