A 60-year-old Korean man was admitted to Soonchunhyang University Hospital because of fever and multiple skin eruptions with crusts for 3 days, which were pruritic and erythematous. Papulonodular lesions were located on the anterior chest wall.
There was a history of pulmonary tuberculosis up to 10 years ago, and he had taken drugs for a year. A year prior to admission, he had had a history of enlargement of both cervical lymph nodes and postprandial epigastric pain, which was diagnosed to be early gastric cancer, Ki-1-positive anaplastic lymphoma, stage IIIB involving right submandibular lymph nodes, left cervical lymph nodes and hepatoduodenal lymph nodes (Fig. 1) without bone marrow involvement. At that time, he was treated with 6 cycle combination chemotherapy of ProMACE-CytaBOM regimen for Ki-1-positive anaplastic lymphoma during 6 months. Subtotal gastrectomy and gastroduodenostomy were performed for early gastric cancer after 2 cycles of chemotherapy. After 6 cycle combination chemotherapy, he was on complete remission of the disease.
On admission, the temperature was 38.4 C, the pulse rate 85/min and the respiration rate 20/min. The blood pressure was 110/70mmHg. He had a chronic ill-looking appearance. The conjunctiva was pale and the sclera was not icteric. There were multiple small sized papulonodular eruptions on the anterior chest wall (Fig. 2). On examination of chest, crackles were heard on left lower lung field. Examinations of heart, abdomen and extremities were not remarkable. Enlargement of peripheral lymph nodes was not seen.
Laboratory evaluation revealed hemoglobin of 7.4g/dl, hematocrit of 22.4 percent, leukocyte of 14,600/mm3 with 66 percent neutrophils and 8 percent lymphocytes and platelet 300,000/mm3. The erythrocyte sedimentation rate was 71 mm/hour. Results of serum chemistry test were normal with exception of LDH 1003.3IU/I, BUN 29.9mg/dl, creatinine 1.9mg/dl. The electrocardiography was normal. Radiologic examination of chest revealed fibrostreaky densities in right upper lobe and CT scan of abdomen showed no intra-abdominal lymphadenopathy. Biopsy of cutaneous lesions on anterior chest wall and bone marrow aspiration and biopsy were performed. Light microscopic examination of skin specimen showed that the dermis was diffusely infiltrated with large pleomorphic tumor cells, which were strongly positive for Ki-1 immunohistochemical stain (Fig. 3, 4). Electromicroscopic examination revealed convoluted nuclei with prominent nuclei and sparse intracytoplasmic organelles (Fig. 5). Bone marrow aspiration and biopsy showed a focus of collection of atypical cells with complete necrosis, suspicious for involvement of malignant lymphoma. On diagnosis of relapsed Ki-1-positive anaplastic lymphoma stage IV, we performed salvage chemotherapy with cisplatin, dexamethasone, mitoxantrone and etoposide but, unfortunately, he died of persistent pancytopenia, followed by sepsis.