|Year : 2021 | Volume
| Issue : 1 | Page : 117-119
Dermatopathic lymphadenitis: Cytological diagnosis
Neeti Nagar, Sheetal Arora, Sunil Ranga
Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
|Date of Submission||25-Nov-2020|
|Date of Decision||20-May-2021|
|Date of Acceptance||22-May-2021|
|Date of Web Publication||26-Jun-2021|
Dr. Sheetal Arora
Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Dermatopathic lymphadenopathy usually presents with multiple enlarged lymph nodes. It is often seen in patients with skin diseases with either exfoliative or eczematoid inflammatory erythrodermas. Multiple enlarged lymph nodes usually point to the diagnosis of lymphoma. Fine-needle aspiration cytology helps in reaching the correct diagnosis at the preliminary stage. There are very few case reports on cytological features of this disease in literature. Here, we describe a case of dermatopathic lymphadenopathy in a 15-year-old female with subtle skin disease.
Keywords: Lymphadenopathy, lymphoma, pigment-laden histiocytes
|How to cite this article:|
Nagar N, Arora S, Ranga S. Dermatopathic lymphadenitis: Cytological diagnosis. Arch Med Health Sci 2021;9:117-9
| Introduction|| |
Dermatopathic lymphadenitis (DLN) is one of the important causes of nonspecific lymph node enlargement. It is associated with many chronic dermatoses, including psoriatic erythroderma, mycosis fungoides (MF), and exfoliative dermatitides. However, there are few cases in literature, which present without associated skin conditions., In such cases, it becomes more difficult to make the diagnosis of DL as the differential diagnosis includes low-grade lymphoma and Langerhans histiocytosis.
The correct diagnosis at the preliminary stage with fine-needle aspiration can prevent the patient to undergo unnecessary investigations and treatment. Here, we discuss the case of a 15-year-old female who presented with multiple enlarged lymph nodes with clinical diagnosis of lymphoma.
| Case Report|| |
A 15-year-old female presented with multiple swellings in the cervical, anterior neck, and inguinal region for 2 years. There was no history of fever, cough, weight loss, or loss of appetite. The patient gave a history of incision and drainage from anterior neck swelling from the local practitioner in the past. However, the swelling recurred within 6 months. On examination, cervical and anterior neck swelling [Figure 1] measured 1 cm × 0.8 cm and 2 cm × 1.5 cm, respectively. Inguinal swelling was approximately 1 cm × 1 cm. The swellings were firm and nontender. The overlying skin was normal. No history of any skin disease was given by the patient. On complete examination, minor eczematous lesions were noticed in the web spaces of both the hands [Figure 2]. Fine-needle aspiration cytology (FNAC) was performed from cervical and anterior neck swellings. Smears examined from neck and inguinal swellings revealed similar morphology. Smears showed a polymorphous population of cells composed of mixed lymphoid cells, histiocytes, Langerhans cells, eosinophils, neutrophils, plasma cells, and pigment-laden macrophages [Figure 3] and [Figure 4]. There were no atypical cells in the smears examined. On the basis of cytological features, the diagnosis of DLN was suggested.
|Figure 1: 15-year-old female presenting with multiple enlarged lymph nodes|
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|Figure 3: Cellular smear showing polymorphous population consisting of lymphoid cells, histiocytes, plasma cells and pigment-laden macrophages. (Giemsa stain, ×10)|
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|Figure 4: Cytology smear showing polymorphous population of lymphocytes in various stages of maturation along with Langerhans cells with cleaved nucleus, plasma cells and pigment-laden macrophages. (Giemsa stain, ×40)|
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| Discussion|| |
DL is a nonneoplastic cause of enlarged lymph nodes. Usual clinical presentation is painless lymphadenopathy accompanied by fever and skin rash. It is one of the rare forms of benign lymphatic hyperplasia and is usually associated with most exfoliative or eczematoid inflammatory erythrodermas, including pemphigus, psoriasis, eczema, neurodermatitis, and atrophia senilis. However, there are cases without skin involvement. In the present case, the patient did not give a history of any associated skin problem and there were no obvious skin lesions. However, on extensive examination, few eczematous lesions were appreciated in web spaces of both hands.
DL is also known as lipomelanotic reticulosis or Pautrier-Woringer disease. The axillary and inguinal lymph nodes are most commonly affected. Few patients also present in the head-and-neck region. In our case, cervical lymph node enlargement was more than the inguinal lymph nodes.
Clinically, the first differential diagnosis was Hodgkin's lymphoma on the basis of age and multiple enlarged lymph nodes. On cytological examination, Hodgkin's lymphoma shows a polymorphous population along with Reed–Sternberg cells. In the present case, a polymorphous population comprising mixed lymphoid cell population, eosinophils, histiocytes, Langerhans cells, neutrophils, plasma cells, multinucleated giant cells, and pigment-laden macrophages was seen. However, there were no Reed–Sternberg cells or atypical cells in the smears examined, ruling out our first differential diagnosis of Hodgkin's lymphoma.
Another lesion which is known to be associated with DL is MF. Fine-needle cytology of the lymph nodes involved by MF shows atypical cells with dense chromatin, irregular nuclear borders, and prominent nucleolus at places. Tumor cells of MF show a predominance of CD4+ T-cells with fewer CD8+ cells. These clonal T-cells show loss of CD7. We ruled out MF in our case as there were no apparent atypical cells in the smears examined. Moreover, it is the disease of the elderly, but no age is exception for it. Clinicopathological correlation and histopathological examination is imperative so that the lesion is not missed.
In the present case, smears were cellular. There were few cells with vesicular, grooved, indented nuclei and abundant eosinophilic granular cytoplasm. These Langerhans cells along with eosinophils persuaded us to include the differential diagnosis of Langerhans histiocytosis. However, this differential diagnosis was ruled out as the presence of numerous pigment-laden macrophages strongly suggested the diagnosis of DLN. DL is characterized by numerous noncohesive, pale histiocyte-like cells. There are pigmented macrophages which are either hemosiderin laden or contain melanin pigment. These cells have abundant cytoplasm and smaller oval, nonfolded nuclei. Some eosinophils are usually present. The background shows small lymphocytes that may appear slightly atypical with small pale, central nucleoli, but the blast forms are less common. Thus, age of the patient, absence of atypical cells in the smears, and clinicopathological correlation helped us in reaching the diagnosis of DL.
For further confirmation, immunocytochemistry is done. Histiocytic cells are S-100 and CD1a positive. Langerhans cells are positive for CD1a and histiocytic cells are positive for S-100. Immunocytochemistry was not performed in this case due to lack of cytological material.
DL is a self-limited disease and often does not require any therapy. Thus, a simple FNAC, minimally invasive modality, can guide the clinician in treating the patient appropriately and to avoid more invasive and expensive surgical excision.
It is, therefore, suggested that in patients presenting with generalized lymphadenopathy with enlarged cervical, axillary, and inguinal group of lymph nodes, the differential diagnosis of DLN should be kept in mind, even in the absence of any obvious skin lesion.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]