Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
James Araujo, PGY2
September 29, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 59 year old woman referred to Oncology
clinic with a diffuse skin rash for one year
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• One year prior to referral, the patient was started on
topical medications for her rash which did not improve
• A skin biopsy at an outside clinic revealed lichenified
dermatitis, consistent with cutaneous T cell lymphoma
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• On presentation to Oncology clinic, the patient
reported severe pruritis, but denied systemic
symptoms
• The original biopsy was reviewed by New York
University dermatopathology, confirming the diagnosis
of cutaneous T cell lymphoma
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•
Past Medical History
– Hypertension
•
Past Surgical History
– Hysterectomy at age 45
•
Social History
– Born in Trinidad
– Denies tobacco, alcohol, or drug use
•
•
•
Family History
– Lung cancer, diabetes, hypertension
– No family history of lymphoma
Allergies
– No known drug allergies
Medications
– Atenolol 25 mg orally once daily
– Multivitamin once daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Exam
• General
Well-developed, in no acute distress
• Vital Signs
T 98.2 F, BP 158/80, HR 95, RR 16, O2 sat 99%
• Skin
Extensive hyperpigmented plaques covering 90% of
body and desquamation over the shoulders and back
• Remainder of physical exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• Complete Blood Count:
WBC 6,700 (Differential: 73% segmented neutrophils;
17% lymphocytes; 8% monocytes)
Hemoglobin 13.1
Hematocrit 38.8
Mean Corpuscular Volume 87
Platelet Count 77,000
• Basic Metabolic and Hepatic Panels were normal
• LDH was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
• Peripheral blood smear revealed no evidence of
Sézary cells
• Molecular studies identified a rearranged T cell
receptor gene
• Human T lymphocyte virus I (HTLV-I) antibodies
were negative
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
• Positron Emission Tomography – Computed
Tomography demonstrated bilateral axillary,
cervical, and inguinal lymphadenopathy, without
central lymphadenopathy
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Interim History
• One month after her initial clinic visit, the patient
began treatment with bexarotene and had a
partial clinical response
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Interim History
• Two months after her initial clinic visit, the
patient had several inpatient admissions for
bacterial and fungal sepsis presenting with
hypothermia
• These septic episodes were thought to be
secondary to skin breakdown
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Cutaneous T cell lymphoma, complicated
by bacterial and fungal sepsis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS