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Have Lesion On Torso, Lymph Node Enlargement In Neck, Increased WBC Level. Taking Keflex. Diagnosis?
Question: Having some health issues relating to Hematology & Dermatology... any advice or suggestions is welcome. My team of physicians has yet to diagnose me.
Feb 2012- Enlarged painless left inguinal node with hydroceles in both testicles (testicular ultrasound findings)
Lymph node recessed after a couple of weeks - no infection was found
Chiropractor advised of granulomas in both lungs in x-rays & asked about any serious lung infections (haven't had any)
XXXXXXX 2012 - Dr observed Eosinophils were elevated (has resolved)
All STD screenings - Negative Mild Hypogonadism diagnosed
July 2012-present - skin lesions on dorsum of hands, top of right leg, left elbow on forearm, occipital scalp, face/hairline
5 biopsies - no organism found as the cause. (fungal-negative, mycobacterium-negative, bacterial cultures negative, parasite-negative)
1st Biopsy of scalp- September: Dermatologist was concerned with the consistent reactivating nature of lesion on right occipital scalp. 6mm punch biopsy:
Pathology indicated: Epidermal Hyperplasia with erosion and scale crust formation. Sections demonstrate a punch biopsy of skin with epidermal acanthuses. Focal epidermal erosion and parakeratosis are present overlying a hair follicle in the dermis. Mild dermal fibrosis and a perivascular lymphocytic inflammatory infiltrate are seen.
Biopsy in october - 4mm biopsy of forearm lesion on day of appearance with no scabbing/scarring present. Pathological findings: Sections show a discrete area of necrosis of the basal layer with a superficial and deep perivascular lymphocytic infiltrate with a few eosinophils, suggestive of arthropod bite reaction. Folliculitis not identified. This is an unusual reaction given the necrosis of the lower half of the epidermis and if not caused by an arthropod bite suggests some other external or XXXXXXX agent. Treated with Permethrin to remove possibility of scabies or demodex infestation. Lesions persisted despite treatment with topical permethrin cream.
Oct 2012- Reynaud's phenomenon began in hands/feet - cold/numb in 4th & 5th digits
Mild evidence of bleeding into nail folds & eponychium in fingers- Suggestive of autoimmune involvement, given family history of autoimmune disorders & dx of celiac disease in 2008.
Oct 2012- High BUN ratio & low alkaline phosphatase, high blood calcium 10.5
Nov 2012- BUN/Creatinine Ratio- 23.3, Alkaline Phosphatase 40U/L, AST 21 U/L, ALT 29 U/L, SED rate 2mm/hr, Urea Nitrogen 18mg/dL, Creatinine 0.77mg/dL, Sodium 140mEq/L, Potassium 3.9mEq/L, Chloride 104 mEq/L, Carbon Dioxide 28mmol/L, Calcium 8.8mg/dL, Protein 6.7g/dL, Albumin 4.5g/dL, Bilirubin 0.5mg/dL
Dec 2012- 4.7thou/uL WBC, 5.08mil/uL, Hemoglobin 15.9g/dL, Hematocrit 45%, MCV 88fL, MCH 31.3pg, MCHC 35.7g/dL, RDW 11.4%, Platelet 181 thou/uL, MPV 9.6fL
Dec 2012- Tested for autoimmune conditions. ANA- Neg, RF 9 IU/mL, Anti-DNA(SLE) 7 IU/mL, ANCA-negative, Anti-myeloperoxidase 1.74EU/mL, Anti-Protease 2.01 EU/mL, CH50Blood 271 CH50 U,
Biopsies continued to be inconclusive., All STD screenings negative
XXXXXXX 4 2012- Presented at dermatology grand rounds @ Vanderbilt - Overall opinion was folliculitis, however no organism has been isolated & previous early lesion states no evidence of folliculitis. Did not have opportunity to ask about differential opinions. Inviting physician stated that a consult from a hematologist or rheumatologist is at my discretion but unable to tell me if either specialty would produce any answers.
XXXXXXX 2012- Nutritional studies conducted. Zinc Serum 56 ug/dL, Vitamin B1 79nmol/L, Vit B2 18nmol/L, Iron Blood 166mcg/dL
Treated with 50mg Zinc Gluconate/day to correct Hypozincemia. Reduced Iron intake.
XXXXXXX - CT scan w/ Contrast of Pelvis- nothing remarkable was found.
XXXXXXX 31 - Infectious Disease consult
CBC- 3.7thou/uL , RBC 4.87mil/uL, Hemoglobin 15.5g/dL, Hematocrit 44.8%, MCV 91.9fL, MCH 31.9pg, MCHC 34.7pg, RDW 12.8%, Platelet 200 thou/uL
Alkaline Phosphatase 37, AST 23 U/L, ALT 30 U/L, SED rate 2mm/hr, BUN Creatinine Ratio 20.9, Sodium 141 mmol/L, Potassium 4.4 mmol/L, Chloride 106 mmol/L, Carbon Dioxide 23 mmol/L, Calcium 9.4mg/dL, Protein 7.1g/dL, Albumin 4.7 g/dL, Globulin 2.4g/dL, Bilirubin 0.5mg/dL, Uric Acid 5.7 mg/dL, Creatinine Kinase 52 U/L,
Anti-teichoic acid antibodies- 1:2H Equivocal
Treated with Zyvox 600mg/BID & Rifampin 300mg/BID, Mupirocin topically for lesions on hands/scalp.
Ova & Parasite stool sample was negative.. However despite my international travel to equatorial Africa and temperate South XXXXXXX She refused to test me for a blood/lymphatic parasite. I do remember having a couple of insect bites on my scalp in 2008/2009 during my first trips to Africa.
Antibiotic therapy did not resolve issue.- WBC count elevated to 4.1 during Zyvox treatment.
HIV 1/2 EIA w/Reflex- Non Reactive
RPR w/ Reflex & titre- Non Reactive
March 2012- Zinc Serum 72ug/dL, Iron Blood 101 mcg/dL, Binding Capacity 260mcg/dL, % Iron Saturation 39%, Ferritin Blood 93 ng/dL
March 28, 2012-
WBC 3.8 thou/uL- Inguinal lymphadenopathy with medium size nodes -Lymph nodes in neck have grown over past few year & now feel a chain of about 6 nodes in left side sent to surgeon for inguinal node biopsy.
Symptoms that have come & gone over past year-
Night sweats (seems to be worse in my pelvic area) but i wake up damp & feels like I have wet the bed.
Difficultly sleeping but very fatigued
Abdominal Pain/Bloating
Frequent Headaches
Shortness of breath (not all the time)
Lesions on inside of bottom lip that resolve after a couple days
Joint pain in hips/wrists
Sudden urge to urinate with little warning has happened on several occasions.
Persistent lower than normal blood counts, namely Platelets 180thou-215thou. Bleed very easily. WBC range from 3.7-5.9 (WBC increased almost 2 fold in past 2 weeks)
09APR- surgery for inguinal node dissection due to the gradual increase in size of the lymph nodes. They stated before the surgery that these nodes are unreliable but decided to move forward with the procedure. Neck lymph nodes are also palpable and have been for several months. During surgery what was thought to be an enlarged lymph node was a lipoma and it was removed. 2 skin biopsies of left arm were inconclusive because lesions had already produced scar tissue and did not give any answers. upper arm biopsy was a dermatofibroma. Lymph node biopsy was performed but specimen was of normal size for the groin & most of the skin lesions I am experiencing are occuring on my left arm, face & scalp. I have much larger lymph nodes in my neck & occipital scalp. The biopsy specimen only showed the following in pathology- Mild Follicular and Paracortical Hyperplasia- no evidence of malignancy.
Since the surgery I have developed even more - lesions on the face, Scalp & neck. As shown in pictures attached. I am concerned about cutaneous lymphomas because my WBC count has increased since surgery but skin lesions have worsened since the increase of white count.
In 2010, I had some kind of circular itchy, shiny patch lesions around my torso/belt line that went away on their own after 6 months. In my research & reading they looked like the photos I have seen of patch phase cutaneous lymphoma. I have not mentioned this to my team of doctors yet, because I have only recently realized that this may be relevant to my current problem. I think I may have mentioned it to my dermatologist or PCP back then but I cannot recall. Nonetheless, no biopsy was performed at that time.
The current problem has waxed and waned over the past 8 months, each time getting worse when it returns. I do not pick or scratch the lesions. Once they appear, they tend to ulcerate on their own & the scabs that form loosen and break away when showering, resulting in considerable bleeding from lesions for several minutes. Dermatologist has stated that she feels that the biopsies we have taken in the past are either too early to result in a diagnosis or too late for reliable data. If too early, the population of lymphocytic infiltrate is incomplete & too late, the lesions show scar tissue from the cycle of scabs loosening when wet & re-healing numerous times prior to biopsy.
2 days ago started experiencing severe pain in neck/base of skull when turning head
in either direction. Pain is proximal to L Occipital lymph node & scalp lesion which has grown & doubled in size in last month. Went to ER for pain & examination due to surgery concerns/risk of systemic infection. Bloodwork showed evidence of Hypokalemia & low UA specific gravity. Alk Phosphatase is still below normal. WBC count 5.9, differential increase in Neutrophils was observed. Eardrum redness was also noted & I advised them that I have felt like I have fluid in my ears for a few months now. Was told it was a neck strain, but given all of the other issues/symptoms I have experienced, I feel it is directly related to the underlying problem. It has not felt much better, even with the Flexerol I was prescribed in the ER.
Please take a look at the images and see if you can give me any ideas.. I am scheduled to see a new dermatologist on Monday morning for a new opinion. They have not performed any flow cytometry or immunophenotyping to see what my WBC population is composed of, do you feel its important to push for that given the fact that the lesions have increased in number which directly correlates with the increase in overall WBC count? Is it possible that I could be producing abnormal WBCs that are depositing in my skin, but its too early to really know if its a cutaneous lymphoma?
I am currently taking Keflex 500mg PO 3xday to help prevent infection in surgical incisions. Which subsequently has caused some stomach pain & diarrhea.
Medical History-
1984 - Cat Scratch Disease
1993 - Pityriasis Rosea
1999/2001 Elbow fracture/surgery repair
2002 - tonsillectomy
2004 - Acute HBV
2008 - Dx with Celiac Sprue - began Gluten Free Diet
2009 - MRSA cellulitis of the nose
2010 - Umbilical Hernia repair
2010 - Shingles (thought to be caused by physical stress of surgery)
Early 2010 - shiny, itchy patch lesions around torso/pelvis & belt-line - spontaneously disappeared without medication.
Late 2010 - Treated with low dose Accutane to clear ongoing acne.
Mar 2012 - Follow up colonoscopy/endoscopy - clean examination - sprue damage not seen.
Family medical history:
Partner - Controlled Genital Herpes
Mom - Type 2 Diabetes, Hypokalemia, Hypothyroidism
Sister- Hypothyroidism
Dad- Unknown medical history
Mat GM- Hypothyroidism, Thromobocytopenia, Hypokalemia, heart disease
Mat GF- Emphesema, COPD XXXXXXX GM- Unknown XXXXXXX GF- COPD, Heart Disease XXXXXXX Aunt- Breast Cancer XXXXXXX Cousin- Colon Cancer
Feb 2012- Enlarged painless left inguinal node with hydroceles in both testicles (testicular ultrasound findings)
Lymph node recessed after a couple of weeks - no infection was found
Chiropractor advised of granulomas in both lungs in x-rays & asked about any serious lung infections (haven't had any)
XXXXXXX 2012 - Dr observed Eosinophils were elevated (has resolved)
All STD screenings - Negative Mild Hypogonadism diagnosed
July 2012-present - skin lesions on dorsum of hands, top of right leg, left elbow on forearm, occipital scalp, face/hairline
5 biopsies - no organism found as the cause. (fungal-negative, mycobacterium-negative, bacterial cultures negative, parasite-negative)
1st Biopsy of scalp- September: Dermatologist was concerned with the consistent reactivating nature of lesion on right occipital scalp. 6mm punch biopsy:
Pathology indicated: Epidermal Hyperplasia with erosion and scale crust formation. Sections demonstrate a punch biopsy of skin with epidermal acanthuses. Focal epidermal erosion and parakeratosis are present overlying a hair follicle in the dermis. Mild dermal fibrosis and a perivascular lymphocytic inflammatory infiltrate are seen.
Biopsy in october - 4mm biopsy of forearm lesion on day of appearance with no scabbing/scarring present. Pathological findings: Sections show a discrete area of necrosis of the basal layer with a superficial and deep perivascular lymphocytic infiltrate with a few eosinophils, suggestive of arthropod bite reaction. Folliculitis not identified. This is an unusual reaction given the necrosis of the lower half of the epidermis and if not caused by an arthropod bite suggests some other external or XXXXXXX agent. Treated with Permethrin to remove possibility of scabies or demodex infestation. Lesions persisted despite treatment with topical permethrin cream.
Oct 2012- Reynaud's phenomenon began in hands/feet - cold/numb in 4th & 5th digits
Mild evidence of bleeding into nail folds & eponychium in fingers- Suggestive of autoimmune involvement, given family history of autoimmune disorders & dx of celiac disease in 2008.
Oct 2012- High BUN ratio & low alkaline phosphatase, high blood calcium 10.5
Nov 2012- BUN/Creatinine Ratio- 23.3, Alkaline Phosphatase 40U/L, AST 21 U/L, ALT 29 U/L, SED rate 2mm/hr, Urea Nitrogen 18mg/dL, Creatinine 0.77mg/dL, Sodium 140mEq/L, Potassium 3.9mEq/L, Chloride 104 mEq/L, Carbon Dioxide 28mmol/L, Calcium 8.8mg/dL, Protein 6.7g/dL, Albumin 4.5g/dL, Bilirubin 0.5mg/dL
Dec 2012- 4.7thou/uL WBC, 5.08mil/uL, Hemoglobin 15.9g/dL, Hematocrit 45%, MCV 88fL, MCH 31.3pg, MCHC 35.7g/dL, RDW 11.4%, Platelet 181 thou/uL, MPV 9.6fL
Dec 2012- Tested for autoimmune conditions. ANA- Neg, RF 9 IU/mL, Anti-DNA(SLE) 7 IU/mL, ANCA-negative, Anti-myeloperoxidase 1.74EU/mL, Anti-Protease 2.01 EU/mL, CH50Blood 271 CH50 U,
Biopsies continued to be inconclusive., All STD screenings negative
XXXXXXX 4 2012- Presented at dermatology grand rounds @ Vanderbilt - Overall opinion was folliculitis, however no organism has been isolated & previous early lesion states no evidence of folliculitis. Did not have opportunity to ask about differential opinions. Inviting physician stated that a consult from a hematologist or rheumatologist is at my discretion but unable to tell me if either specialty would produce any answers.
XXXXXXX 2012- Nutritional studies conducted. Zinc Serum 56 ug/dL, Vitamin B1 79nmol/L, Vit B2 18nmol/L, Iron Blood 166mcg/dL
Treated with 50mg Zinc Gluconate/day to correct Hypozincemia. Reduced Iron intake.
XXXXXXX - CT scan w/ Contrast of Pelvis- nothing remarkable was found.
XXXXXXX 31 - Infectious Disease consult
CBC- 3.7thou/uL , RBC 4.87mil/uL, Hemoglobin 15.5g/dL, Hematocrit 44.8%, MCV 91.9fL, MCH 31.9pg, MCHC 34.7pg, RDW 12.8%, Platelet 200 thou/uL
Alkaline Phosphatase 37, AST 23 U/L, ALT 30 U/L, SED rate 2mm/hr, BUN Creatinine Ratio 20.9, Sodium 141 mmol/L, Potassium 4.4 mmol/L, Chloride 106 mmol/L, Carbon Dioxide 23 mmol/L, Calcium 9.4mg/dL, Protein 7.1g/dL, Albumin 4.7 g/dL, Globulin 2.4g/dL, Bilirubin 0.5mg/dL, Uric Acid 5.7 mg/dL, Creatinine Kinase 52 U/L,
Anti-teichoic acid antibodies- 1:2H Equivocal
Treated with Zyvox 600mg/BID & Rifampin 300mg/BID, Mupirocin topically for lesions on hands/scalp.
Ova & Parasite stool sample was negative.. However despite my international travel to equatorial Africa and temperate South XXXXXXX She refused to test me for a blood/lymphatic parasite. I do remember having a couple of insect bites on my scalp in 2008/2009 during my first trips to Africa.
Antibiotic therapy did not resolve issue.- WBC count elevated to 4.1 during Zyvox treatment.
HIV 1/2 EIA w/Reflex- Non Reactive
RPR w/ Reflex & titre- Non Reactive
March 2012- Zinc Serum 72ug/dL, Iron Blood 101 mcg/dL, Binding Capacity 260mcg/dL, % Iron Saturation 39%, Ferritin Blood 93 ng/dL
March 28, 2012-
WBC 3.8 thou/uL- Inguinal lymphadenopathy with medium size nodes -Lymph nodes in neck have grown over past few year & now feel a chain of about 6 nodes in left side sent to surgeon for inguinal node biopsy.
Symptoms that have come & gone over past year-
Night sweats (seems to be worse in my pelvic area) but i wake up damp & feels like I have wet the bed.
Difficultly sleeping but very fatigued
Abdominal Pain/Bloating
Frequent Headaches
Shortness of breath (not all the time)
Lesions on inside of bottom lip that resolve after a couple days
Joint pain in hips/wrists
Sudden urge to urinate with little warning has happened on several occasions.
Persistent lower than normal blood counts, namely Platelets 180thou-215thou. Bleed very easily. WBC range from 3.7-5.9 (WBC increased almost 2 fold in past 2 weeks)
09APR- surgery for inguinal node dissection due to the gradual increase in size of the lymph nodes. They stated before the surgery that these nodes are unreliable but decided to move forward with the procedure. Neck lymph nodes are also palpable and have been for several months. During surgery what was thought to be an enlarged lymph node was a lipoma and it was removed. 2 skin biopsies of left arm were inconclusive because lesions had already produced scar tissue and did not give any answers. upper arm biopsy was a dermatofibroma. Lymph node biopsy was performed but specimen was of normal size for the groin & most of the skin lesions I am experiencing are occuring on my left arm, face & scalp. I have much larger lymph nodes in my neck & occipital scalp. The biopsy specimen only showed the following in pathology- Mild Follicular and Paracortical Hyperplasia- no evidence of malignancy.
Since the surgery I have developed even more - lesions on the face, Scalp & neck. As shown in pictures attached. I am concerned about cutaneous lymphomas because my WBC count has increased since surgery but skin lesions have worsened since the increase of white count.
In 2010, I had some kind of circular itchy, shiny patch lesions around my torso/belt line that went away on their own after 6 months. In my research & reading they looked like the photos I have seen of patch phase cutaneous lymphoma. I have not mentioned this to my team of doctors yet, because I have only recently realized that this may be relevant to my current problem. I think I may have mentioned it to my dermatologist or PCP back then but I cannot recall. Nonetheless, no biopsy was performed at that time.
The current problem has waxed and waned over the past 8 months, each time getting worse when it returns. I do not pick or scratch the lesions. Once they appear, they tend to ulcerate on their own & the scabs that form loosen and break away when showering, resulting in considerable bleeding from lesions for several minutes. Dermatologist has stated that she feels that the biopsies we have taken in the past are either too early to result in a diagnosis or too late for reliable data. If too early, the population of lymphocytic infiltrate is incomplete & too late, the lesions show scar tissue from the cycle of scabs loosening when wet & re-healing numerous times prior to biopsy.
2 days ago started experiencing severe pain in neck/base of skull when turning head
in either direction. Pain is proximal to L Occipital lymph node & scalp lesion which has grown & doubled in size in last month. Went to ER for pain & examination due to surgery concerns/risk of systemic infection. Bloodwork showed evidence of Hypokalemia & low UA specific gravity. Alk Phosphatase is still below normal. WBC count 5.9, differential increase in Neutrophils was observed. Eardrum redness was also noted & I advised them that I have felt like I have fluid in my ears for a few months now. Was told it was a neck strain, but given all of the other issues/symptoms I have experienced, I feel it is directly related to the underlying problem. It has not felt much better, even with the Flexerol I was prescribed in the ER.
Please take a look at the images and see if you can give me any ideas.. I am scheduled to see a new dermatologist on Monday morning for a new opinion. They have not performed any flow cytometry or immunophenotyping to see what my WBC population is composed of, do you feel its important to push for that given the fact that the lesions have increased in number which directly correlates with the increase in overall WBC count? Is it possible that I could be producing abnormal WBCs that are depositing in my skin, but its too early to really know if its a cutaneous lymphoma?
I am currently taking Keflex 500mg PO 3xday to help prevent infection in surgical incisions. Which subsequently has caused some stomach pain & diarrhea.
Medical History-
1984 - Cat Scratch Disease
1993 - Pityriasis Rosea
1999/2001 Elbow fracture/surgery repair
2002 - tonsillectomy
2004 - Acute HBV
2008 - Dx with Celiac Sprue - began Gluten Free Diet
2009 - MRSA cellulitis of the nose
2010 - Umbilical Hernia repair
2010 - Shingles (thought to be caused by physical stress of surgery)
Early 2010 - shiny, itchy patch lesions around torso/pelvis & belt-line - spontaneously disappeared without medication.
Late 2010 - Treated with low dose Accutane to clear ongoing acne.
Mar 2012 - Follow up colonoscopy/endoscopy - clean examination - sprue damage not seen.
Family medical history:
Partner - Controlled Genital Herpes
Mom - Type 2 Diabetes, Hypokalemia, Hypothyroidism
Sister- Hypothyroidism
Dad- Unknown medical history
Mat GM- Hypothyroidism, Thromobocytopenia, Hypokalemia, heart disease
Mat GF- Emphesema, COPD XXXXXXX GM- Unknown XXXXXXX GF- COPD, Heart Disease XXXXXXX Aunt- Breast Cancer XXXXXXX Cousin- Colon Cancer
Hi,
I have gone through your detailed clinical history and the images attached.
I would first like to make few clarifications
1) the lesion on your torso could have been a fungal infection. There is no reason to believe these could have been the lesions of cutaneous T cell lymphoma
2) the lymph node enlargement in your neck could be due to lesions in your scalp this is known as reactive lymphadenopathy
3) again increase in WBC count could be due to lesions that you are having. In wake of any infection, our body increases the pathogen fighting cells or leucocytosis.
Now coming to your skin lesions, the lesions over your face look a bit excoriated or scratched. Small raised red lesions and few water filled lesions or vesicular are seen over scalp. These clinical findings and the site involved leads me to think of few possiblities
Dermatitis herpetiformis- an association with coeliac disease has been seen. It is characterised by papulovesicular lesions( raised red lesions and pin point blisters) usually over scalp, face, hairline, back, extensors of limbs, elbows etc. the lesions are extremely itchy.
Skin biopsy is extremely helpful and should be taken from a fresh non excoriated lesion. Dapsone as treatment offers wonderfully response.
Folliculitis or a bacterial infection - boils develop and treatment requires antibiotics. Course of rifampicin helps too.
Your face lesions look like demodex infection too but involvement of other sites like elbow etc goes against it.
As you have an appointment with a dermatologist on Monday , I would advise that you may discuss the possibility of dermatitis herpetiformis with him. Secondly nothing is better than a naked eye clinical examination of the lesions as dermatology is completely a visual field.
Hope I have proved to be of some help.
Regards
I have gone through your detailed clinical history and the images attached.
I would first like to make few clarifications
1) the lesion on your torso could have been a fungal infection. There is no reason to believe these could have been the lesions of cutaneous T cell lymphoma
2) the lymph node enlargement in your neck could be due to lesions in your scalp this is known as reactive lymphadenopathy
3) again increase in WBC count could be due to lesions that you are having. In wake of any infection, our body increases the pathogen fighting cells or leucocytosis.
Now coming to your skin lesions, the lesions over your face look a bit excoriated or scratched. Small raised red lesions and few water filled lesions or vesicular are seen over scalp. These clinical findings and the site involved leads me to think of few possiblities
Dermatitis herpetiformis- an association with coeliac disease has been seen. It is characterised by papulovesicular lesions( raised red lesions and pin point blisters) usually over scalp, face, hairline, back, extensors of limbs, elbows etc. the lesions are extremely itchy.
Skin biopsy is extremely helpful and should be taken from a fresh non excoriated lesion. Dapsone as treatment offers wonderfully response.
Folliculitis or a bacterial infection - boils develop and treatment requires antibiotics. Course of rifampicin helps too.
Your face lesions look like demodex infection too but involvement of other sites like elbow etc goes against it.
As you have an appointment with a dermatologist on Monday , I would advise that you may discuss the possibility of dermatitis herpetiformis with him. Secondly nothing is better than a naked eye clinical examination of the lesions as dermatology is completely a visual field.
Hope I have proved to be of some help.
Regards
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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