Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Study Letters
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
Therapy Letters
View Point
What’s new in Dermatology
View/Download PDF

Translate this page into:

Letter to the Editor - Observation Letter
doi: 10.4103/0378-6323.190851
PMID: 27643547

Leukemia cutis preceding bone marrow relapse in acute monocytic leukemia

Najmaddin Khoshnaw1 , Belal A Muhammad2
1 Department of Hematology, Hiwa Hospital; Department of Clinical Hematology, Kurdistan Board of Medical Specialties, Kurdistan Region, Iraq
2 Department of Medical Laboratory Techniques, Technical Institute of Halabja, Sulaimani Polytechnic University; Department of Medical Laboratory Sciences, College of Science, Komar University of Science and Technology, Iraq

Correspondence Address:
Najmaddin Khoshnaw
Department of Haematology, Hiwa Hospital, Sulaymaniyah, Kurdistan Region
How to cite this article:
Khoshnaw N, Muhammad BA. Leukemia cutis preceding bone marrow relapse in acute monocytic leukemia. Indian J Dermatol Venereol Leprol 2016;82:713-716
Copyright: (C)2016 Indian Journal of Dermatology, Venereology, and Leprology


Leukemia cutis is a non-specific term used to describe an extra-medullary manifestation of any type of leukemia characterized by skin infiltration (epidermis, dermis or subcutaneous tissues) with neoplastic leukemic cells resulting in clinically identifiable skin lesions.[1],[2],[3]

A 50-year-old woman presented to the hematology department with a 2-week history of generalized nodular skin lesions along with mild bone pain and fever. The patient had a history of acute monocytic leukemia which was diagnosed 6 months prior to the present admission. She experienced a complete remission which lasted for 5–6 months following an induction course of chemotherapy with cytosine arabinocide and daunorubicin (7 + 3) and three additional consolidation courses of the same protocol (5 + 2).

On examination, we found that the skin lesions were of different shapes and sizes ranging from small to large nodules (0.5–3.0 cm in diameter), bullae and erythematous plaques distributed all over the body including the trunk and the ventral aspect of extremities. Tender nodules were felt on the extensor surface of the hands and shin [Figure - 1]a,[Figure - 1]b,[Figure - 1]c,[Figure - 1]d. She also had mild splenomegaly. A biopsy from the largest skin nodule on the upper part of the right leg revealed extensive mononuclear blast cell infiltration in the dermis and the subcutaneous tissue. The blasts had relatively abundant cytoplasm with dispersed chromatin [Figure - 2]a,[Figure - 2]b,[Figure - 2]c. Bone marrow examination at this point revealed 2% blasts and no blasts were detected in the peripheral blood film.

Figure 1a: Morphological appearance of the skin lesions. Generalized skin lesions, consisting of violaceous subcutaneous nodules, papules, bullae and erythematous lesions on abdomen, per-umbilical
Figure 1b: Morphological appearance of the skin lesions. Generalized skin lesions, consisting of violaceous subcutaneous nodules, papules, bullae and erythematous lesions on extensor surface of the hand showing a large nodule (3 cm × 2 cm).
Figure 1c: Morphological appearance of the skin lesions. Generalized skin lesions, consisting of violaceous subcutaneous nodules, papules, bullae and erythematous lesions on lower extremities (plaster indicates the site of the skin biopsy)
Figure 1d: Morphological appearance of the skin lesions. Generalized skin lesions, consisting of violaceous subcutaneous nodules, papules, bullae and erythematous lesions on extensor surface of the forearms showing skin lesions
Figure 2a: Skin biopsy and bone marrow aspiration. Skin biopsy showing extensive infi ltration of dermis and subcutaneous tissue by mononuclear cells (H and E, ×40)
Figure 2b: Skin biopsy and bone marrow aspiration. Skin biopsy showing extensive infi ltration of dermis and subcutaneous tissue by mononuclear cells (H and E, ×200)
Figure 2c: Skin biopsy and bone marrow aspiration. Skin biopsy showing extensive infi ltration of dermis and subcutaneous tissue by mononuclear cells (H and E, ×400)

Three weeks following the appearance of the initial skin lesions, the symptoms gradually worsened and the patient developed severe pain in the bones coupled with high fever, anorexia, night sweats and productive cough with purpura and ecchymosis in the skin. Physical examination revealed gum hypertrophy with mild splenomegaly. Laboratory investigations revealed moderate anemia, leukocytosis and severe thrombocytopenia with an erythrocyte sedimentation rate of 76 mm/h and raised lactate dehydrogenase levels of 564 IU.

Further investigations revealed obvious signs of relapsed acute monocytic leukemia in both the peripheral blood smear (5% of blasts) and the bone marrow aspirate (32% blasts) [Figure - 2]d. The blast cells were large with abundant moderately basophilic cytoplasm. Although a partial remission was obtained after a course of aggressive chemotherapy with FLAG-IDA (fludarabine 30 mg/m[2], Ara-C 2 g/m[2] for 5 days, idarubicin 10 mg/m[2] for 3 days and granulocyte-colony stimulating factor from day 6 until neutrophil recovery), the patient could not achieve a complete remission. Eventually, she died 35 days after the initial presentation with skin lesions. Death was attributed to complications including severe febrile neutropenia and septicemia.

Figure 2d: Skin biopsy and bone marrow aspiration. Bone marrow aspiration showing extensive infiltration by monocytes and monoblasts (Leishman, ×400)

Leukemia cutis is an extramedullary skin infiltration which usually occurs in leukemias, especially in acute monocytic and myelomonocytic leukemias. It may, sometimes, occur before the appearance of peripheral and/or bone marrow leukemia (called aleukemic leukemia cutis) or it may occur concomitantly with systemic leukemia or after a complete remission. The duration may range from weeks to months or even more.[4] Cases of leukemia cutis are often associated with a bad prognosis.[1],[5],[6] Therefore, once a patient is diagnosed to have leukemia cutis, urgent treatment with aggressive chemotherapy is required. Our patient was treated with FLAG-IDA protocol and had entered a period of pancytopenia and febrile neutropenia but eventually died 35 days after the diagnosis of leukemia cutis.

Isolated extramedullary recurrence of acute non-lymphoblastic leukemias always heralds bone marrow relapse and should be treated with re-induction chemotherapy.[7] The increased risk of extramedullary relapse is presumably related to the higher incidence of extramedullary disease as in FAB (French–American–British classification) M4 and M5 subclasses.[8] However, very rarely, leukemia cutis precedes peripheral or bone marrow leukemia as noted in our case.

To sum up, we describe a case of aleukemic leukemia cutis which preceded the relapse of acute monocytic leukemia occurring after a complete remission, with aggressive symptoms and a very short survival time. Due to its aggressive clinical presentation, we strongly recommend that aleukemic leukemia cutis be carefully sought when patients with a history of leukemia, when develop cutaneous nodules.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Ansell LH, Mehta J, Cotliar J. Recurrent aleukemic leukemia cutis in a patient with pre-B-cell acute lymphoblastic leukemia. J Clin Oncol 2013;31:e353-5.
[Google Scholar]
Cho-Vega JH, Medeiros LJ, Prieto VG, Vega F. Leukemia cutis. Am J Clin Pathol 2008;129:130-42.
[Google Scholar]
Wagner G, Fenchel K, Back W, Schulz A, Sachse MM. Leukemia cutis – Epidemiology, clinical presentation, and differential diagnoses. J Dtsch Dermatol Ges 2012;10:27-36.
[Google Scholar]
Barzilai A, Lyakhovitsky A, Goldberg I, Meytes D, Trau H. Aleukemic monocytic leukemia cutis. Cutis 2002;69:301-4.
[Google Scholar]
Kaddu S, Zenahlik P, Beham-Schmid C, Kerl H, Cerroni L. Specific cutaneous infiltrates in patients with myelogenous leukemia: A clinicopathologic study of 26 patients with assessment of diagnostic criteria. J Am Acad Dermatol 1999;40(6 Pt 1):966-78.
[Google Scholar]
Su WP. Clinical, histopathologic, and immunohistochemical correlations in leukemia cutis. Semin Dermatol 1994;13:223-30.
[Google Scholar]
Byrd JC, Edenfield WJ, Shields DJ, Dawson NA. Extramedullary myeloid cell tumors in acute nonlymphocytic leukemia: A clinical review. J Clin Oncol 1995;13:1800-16.
[Google Scholar]
Harris AC, Kitko CL, Couriel DR, Braun TM, Choi SW, Magenau J, et al. Extramedullary relapse of acute myeloid leukemia following allogeneic hematopoietic stem cell transplantation: Incidence, risk factors and outcomes. Haematologica 2013;98:179-84.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections