case_images: PMC10758200_01
case_images: (A) Erythematous plaque with scale crust on lower abdomen. (B) Punch biopsy demonstrating superficial dermal and intraepidermal infiltrates of atypical lymphocytes with fibroplasia and parakeratosis (H&E 50x). (C) CD3, (D) CD4, (E) CD8, (F) CD7 immunostains (H&E 50x).
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case_images: fig1
case_images: Physical examination findings are shown in Figure 1A. He underwent biopsy that showed superficial dermal and intraepidermal infiltrates of atypical CD3 expressing lymphocytes with decreased expression of CD7 and slight predominance of CD4 over CD8 (Figures 1B-F).
case_images: (A) Erythematous, lichenified and excoriated plaques with serum seepage on forearm and leg. (B) Punch biopsy demonstrating psoriasiform dermatitis with dermal lymphocytic infiltrate (H&E 50x). (C) CD3, (D) CD4, (E) CD8 immunostains (H&E 50x). (F) Immunosequencing data demonstrating the TCRbeta sequence of the dominant (malignant) clone and its frequency among all cells for each indicated blood or skin biopsy specimen. T-cell Receptor (TCR), Tumor Clone Frequency (TCF), Total Skin Electron Beam Therapy (TSEBT), Moga (Mogamulizumab).
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case_images: fig2
case_images: Biotechnologies) identified one dominant TCRbeta sequence present in two separate skin biopsies (Figure 2F). Blood immunosequencing also identified a dominant TCRbeta sequence identical to the dominant clone detected in skin (Figure 2F). One year later, blood and skin evaluation revealed the persistence of the dominant clone with sustained frequencies and unchanged B1 status by flow cytometry (Figure 2F). Four months after starting mogamulizumab therapy, the patient developed a new, worsening rash that clinically resembled his MF (Figure 2A). Biopsy findings demonstrated a psoriasiform spongiotic dermatitis with a dermal infiltrate of CD3+ cells, predominance of CD8 over CD4, and no epidermotropism (Figures 2B-E). Immunosequencing did not detect the previously identified malignant clone or any other dominant clones in either blood or skin biopsies (Figure 2F).
case_images: PMC10758200_02
case_images: Erythematous patches and thin purple-red plaques involving most skin surface areas on (A) back and (B) posterior thigh. (C) Indurated, lichenified plaque with well-defined border on posterior neck. (D) Erythematous papules and ill-defined erythematous patch on flank. (E) CD4, (F) CD8 immunostains. (G) Immunosequencing data demonstrating the TCRbeta sequence of the dominant (malignant) clone and its frequency among all cells for each indicated blood or skin biopsy specimen. Extracorporeal Photopheresis (ECP), Moga (Mogamulizumab), T-cell Receptor (TCR), Tumor Clone Frequency (TCF).
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case_images: fig3
case_images: An 88-year-old female presented with a pruritic rash on her back, chest, buttocks, and upper and lower extremities (Figures 3A,B). Immunosequencing identified a dominant TCRbeta sequence shared both in the blood and skin (Figure 3G). In contrast, blood immunosequencing showed unchanged frequencies of the previously identified malignant clone (Figure 3G). Five months after beginning mogamulizumab, the patient developed a new rash on the neck and flank resembling her MF (Figures 3C,D). The majority of lymphocytes expressed CD3 and CD8, and a minority expressed CD4 (Figures 3E,F). Immunosequencing did not identify a dominant clone in skin or blood (Figure 3G), excluding MF from the differential and confirming the diagnosis of MAR.
case_images: PMC10758200_03
case_images: (A) Erythematous patches on the abdomen. (B) Diffuse erythema on the back. (C) Punch biopsy demonstrating superficial dermal fibroplasia with atypical epidermotropic lymphocytes seen in the epidermis as microabscesses (H&E 100x). (D) Punch biopsy demonstrating superficial perivascular dermatitis with telangiectasis within the papillary dermis (H&E 100x). (E) Immunosequencing data demonstrating the TCRbeta sequence of the dominant (malignant) clone and its frequency among all cells for each indicated blood or skin biopsy specimen. T-cell Receptor (TCR), Tumor Clone Frequency (TCF).
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case_images: PMC10758200_03_fmed-10-1243459-g004.jpg
case_images: fig4
case_images: A 90-year-old female presented with a year-long history of eczematous patches on the trunk and extremities (Figure 4A). Biopsy of an abdominal lesion demonstrated fibroplasia with dermal and epidermal infiltration of atypical CD3+, CD4+ lymphocytes with diminished CD7 expression that formed Pautrier's microabscesses (Figure 4C). Immunosequencing of skin biopsy demonstrated one dominant TCRbeta sequence (Figure 4E). Peripheral blood flow cytometry analysis did not detect blood involvement by MF and immunosequencing of the blood did not identify a dominant T-cell clone (Figure 4E). Physical exam revealed diffuse erythema accompanied by fissuring and oozing in abdominal folds and back (Figure 4B). The biopsy showed superficial perivascular dermatitis with telangiectasis within the papillary dermis (Figure 4D). Immunosequencing did not reveal a clonal population (Figure 4E).