Case Presentation:
The patient is a 27 year old male with no past medical history who presented to our Emergency Department, part of a large urban/suburban tertiary care center. He complained of left upper arm swelling, pain and an ulcerated lesion with serosanguinous drainage for three weeks and high fevers for one week. No trauma, animal bites or insect bites were reported. He was initially treated at an outside hospital with antibiotics, and presented here as he was not improving.
On admission, physical exam was significant for a 2 centimeter ulcerated lesion with surrounding induration (see figure), erythema, edema and serosanguinous drainage with minimal tenderness. No fluctuance was noted. Left supraclavicular and axillary lymph nodes were enlarged. Labs were significant for transaminitis (AST 143, ALT 204), creatinine 1.25, mild microcytic anemia with hemoglobin/hematocrit 12.6/38.1. The white blood cell count with differential was normal. Infectious Disease was consulted. He was treated for cellulitis with abscess initially with Vancomycin and Pipercillin/Tazobactam, and later with Daptomycin. CT scan of the left upper extremity did not reveal any abscess. Abdominal sonogram and hepatitis panel were negative. Blood and wound cultures were negative for bacteria,fungus and acid fast bacilli. HIV testing and a rheumatologic workup were negative. Skin biopsy was performed, reported preliminarily as possible discoid lupus. He was started on steroids, defervsed and was discharged home. A final diagnosis of subcutaneous panniculitis‐like T cell lymphoma (SPTCL) required prolonged consultations with multiple pathologists and the National Institute of Health. As outpatient, steroids were discontinued, and he was started on cyclosporine per oncology recommendations. Patient is currently doing well.
Discussion:
SPTCL is a peripheral T cell lymphoma derived from a mature cytotoxic T cell that accounts for less than 1 percent of non‐Hodgkin lymphoma, and typically presents with one or more often painless subcutaneous nodules or indurated plaques involving the legs, arms, trunk, and/or face. Necrosis may be present, but ulceration is uncommon. Single lesions are rare. Interestingly, our patient had only a single lesion. Most patients with SPTCL have an indolent course with a five‐year overall survival rate of approximately 80%.
Conclusions:
This case highlights the importance of rethinking the diagnosis of cellulitis when the patient fails to improve on antibiotics and being aware of the non infectious masqueraders of cellulitis such as contact dermatitis, deep vein thrombosis, acute gout, drug reactions, insect bites, and malignancy.
