Cutaneous T-cell lymphoma presenting as disseminated, pigmented, purpura-like eruption

A 48-year-old man with a history of psoriasis, who had received no oral pha rmacologic treatment, presented in March 2000 with a progressive, cutaneous , pruritic eruption that began on his arms and legs, and became generalized . Examination revealed discrete, purpuric elements disseminated over the en tire cutaneous surface, and in some areas confluent, large, erythematous, p urpuric patches (Figs 1 and 2). The palmoplantar surfaces and mucous membra nes were spared. No lesions suggesting parapsoriasis or the usual presentat ion of cutaneous T-cell lymphoma (CTCL) were present. Histopathologic examination of a cutaneous specimen showed numerous atypica l lymphocytes in the superficial dermis, slight changes at the dermo-epider mal junction, and an intense epidermotrophism, with atypical lymphocytes in the epidermis. These intraepidermal atypical lymphocytes were present both isolated and forming aggregates of 4-7 cells (Fig. 3). Immunohistochemical studies demonstrated that these lymphocytes were T-helper cells. Routine laboratory tests were normal, except for slight hypercholesterolemi a. Direct examination of peripheral blood, coagulation. antinuclear antibod y (ANA) immunofluorescent test, body scanner, and bone marrow study were no rmal. CTCL stage IB was diagnosed and psoralen plus UVA (PUVA) therapy was initia ted.