A 64-year-old male, with no relevant past medical history, was referred to the outpatient clinic due to recurrent, painless and indurated cutaneous nodules in the lower limbs for approximately 45 days.
He did not suffer from illness, he did not report weight loss, fever, or constitutional syndrome.
Physical examination revealed several lesions in the form of nodular subcutaneous plaques measuring 1 to 3 cm in diameter, erythematous-violaceous, symmetrical, hard and painless, located on both shoulders.
There were no adenopathies or visceromegaly and there were signs of superficial thromboflebitis in the right lower limb.
Laboratory tests revealed: leukocytes 12.3 x 109/L (neutrophils 6.8, lymphocytes 1.1, monocytes 4.3, eosinophils 0.1), Hb 120 g/L, MCV 109.8 fL; Hto.
32%; platelets 133 x 109/L. Pelgueroid granulocytes were observed (non-segmented or hyposegmented nuclei) and mild necrosis.
Reticulocytes: 2.4% (totals 86.4 x 109/L), VSG 60 mm/h; immunoglobulins, proteinogram, hemostasis tests, urine and sediment, iron, vitamin B12 and folic acid study,
Echo-Doppler of lower limb thrombosis was performed, resulting in a superficial thrombophlebitis of the internal saphenous vein of the right lower limb with thrombosis of that vein and an important edematous component of the surrounding venous fat tissue, without thrombosis.
In several subsequent blood counts the number of monocytes in blood remained significantly high.
1.
A biopsy of a skin lesion showed the presence of panlobular granulomatous panlobular panlobular granulomatous necrosis with erythema induratum of Bazin or nodular vasculitis, associated with organized venous thrombosis.
A battery of diagnostic tests was performed to rule out infectious causes (KB, culture and PCR analysis for Mycobacterium tuberculosis: negative sputum culture; serology for recent infection by Toxoplasma capsular antigen; serology negative for penicillin-
Ziehl-Neelsen stain in the skin biopsy sample (for the differential diagnosis of the microscopic lesion observed should be established mainly with a cutaneous mycobacterial infection) was also negative.
1.
The presence in blood of granulocytic forms manifests itself as a signifi cant mental disorder. The patient is a moderated monocytic neoplasm Service. In this case, a medullary nucleus aspiration was performed. There was a predominance of hypercellular monocytes.
The karyotype was normal, 46XY.
With all this the patient was diagnosed of CMML with nonspecific cutaneous involvement panbulillar type.
The patient was treated with oral corticoids (prednisone 30 mg/day, with weekly reduction regimen), with resolution of the skin lesions a few days after starting this treatment.
Currently, three years after diagnosis and without treatment since then, he is asymptomatic, with mild anemia, MCV 110.9 fL, platelets 143 x 109/L, and monocytosis of 2.3 x 109/l bone marrow in quarterly blood.
