Ultra-late erysipeloid angiotropic metastatic malignant melanoma

In 1998, a 70-year-old white man developed a slowly increasing swelling of the right lower extremity of 5 months' duration. During the 3 weeks prior t o presentation, the patient noted intensifying erythema accompanied by incr easing tenderness and warmth on palpation. A clinical diagnosis of cellulit is, was made and the patient underwent a 2-week course of oral cephalexin, 500 mg four times a day, without improvement. Dermatology was consulted. The pertinent past medical history included: (i) wide local excision of a C lark's level II malignant melanoma from the left lower back in 1980; (ii) m etastatic malignant melanoma involving the bladder removed by cystectomy in 1995, together with left inguinal node resection followed by systemic chem otherapy and radiation therapy; (iii) recurrent metastatic malignant melano ma on the right inguinal node, resected, and followed by docetaxel therapy in 1997 with resolution. Physical examination disclosed an ill-looking, elderly man with a moderatel y well-demarcated, elevated, slightly tender, edematous, warm, erythematous , confluent plaque involving the proximal right lower extremity and the rig ht lower flank, suggestive of erysipelas (Fig. 1). Histologic examination r evealed infiltration of the superficial and deep dermal vessels (mainly. sm all venules) by highly anaplastic cells (Fig. 2). The vascular lumina were occluded with the neoplastic cells and focal microthrombi formation. Immuno histochemical staining for S-100 protein, HMB-45, and vimentin confirmed th e diagnosis of metastatic melanoma. CD31 Immunostaining decorated the endot helial lining of the dermal vessels. Tissue cultures and. special stains fo r bacteria and fungi, were negative. A diagnosis of erysipeloid metastatic malignant melanoma involving the vessels was made. The patient and the fami ly declined further aggressive treatments, and the patient died within a fe w weeks under hospice care.