Publications

A 64-year-old married woman was referred to us with a history of pruritic hyperpigmented lesions over the extensor aspects of her limbs, which started as black papular, umbilicated lesions and eventually gave way over a period of a few days to weeks to give rise to crateriform ulcers with a raised border, present over the lower limbs and upper limbs but sparing the trunk and genitalia [Figures 1 and 2]. She was diagnosed as a case of non-Hodgkins lymphoma (NHL) stage IV undergoing a phenomenon called transformation where indolent follicular lymphoma cells get transformed into the much aggressive diffuse large B cell lymphoma (DLBCL). The diagnosis was based upon a lymph node biopsy, a bone marrow biopsy, and the involvement of multiple internal organs such as the liver and spleen. She was started on the Bendamustine–Rituximab chemotherapy regimen (Bendamustine was given at a dose of 90 mg/m2 as a 30-minute infusion on days 1 and 2, combined with 375 mg/m2 rituximab on day 1, and was repeated every 4 weeks for a minimum 4 to 6 cycles). She developed the lesions soon after the second cycle of chemotherapy, which she had taken approximately 2 months after the first cycle. The delay in administering the second cycle of chemotherapy was largely owing to noncompliance on the part of the patient. However, in view of regression of disease activity and the lack of any viable and effective alternative options, the chemoimmunotherapy was continued regardless up to the sixth cycle in spite of the gradual increase in the number of lesions and the severity of pruritus associated with it. The progress of the lesions was arrested on completion of therapy, and remained status quo in terms of number and pruritic severity until the time the patient consulted with us a few weeks later. At this time, the patients' disease was adjudged to be in regression. There was no history of pruritus prior to the onset of therapy and no history suggestive of any other dermatoses, paraneoplastic symptoms, tumour metastasis, internal organ involvement, and metabolic disorders, including evidence of kidney injury.