Images in vascular medicine

Abstract

A 61-year-old Caucasian female with prior history of bilateral femoro-popliteal bypass grafts, chronic venous insufficiency and long-standing rheumatoid arthritis was admitted with painful bilateral lower extremity ulcerations. Presumptive diagnosis of infected venous or vasculitic ulcers was made and vascular medicine consultation was obtained. Anterolateral aspects of bilateral lower extremities were erythematous and revealed several tender ulcers with well-defined edges. The ulcer bases were composed of predominantly pale granulation tissue and serous discharge (Panel A). Ankle‐brachial index and toe pressures were normal at rest. Pertinent laboratory results included a rheumatoid factor of 392 IU/ml and a Westergren sedimentation rate of 115 mm/h. The serum cryoglobulins, C-ANCA, PANCA and complement levels (C3/C4) were within normal limits. An MRI did not suggest osteomyelitis. A wound biopsy was requested due to the atypical nature of the ulcers and revealed cutaneous large T-cell lymphoma. Panel B shows the microscopic appearance of the large T-cell lymphoma with angioinvasive features. Beneath an ulcerated epidermis, malignant lymphoid cells infiltrate the deep dermis and subcutis and invade small and medium-sized arterioles in the deep dermis (1: hematoxylin and eosin, 200). At higher magnification, the cells have a large cell morphology (2: hematoxylin and eosin, 400). Immunohistochemistry for the T-cell-associated antigen CD3 shows a brown colorimetric reaction decorating the cytoplasmic membranes of the neoplastic cells (3: anti-CD3, 400). CHOP chemotherapy was started but she died several months after the diagnosis. Malignant transformation of chronic ulcers is well documented, although uncommon. 1 Patients with rheumatoid arthritis frequently present with leg ulceration 2 and are at increased risk for lymphoma. 3