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Images in Clinical Practice
ARTICLE IN PRESS
doi:
10.25259/IJDVL_425_2021

Multiple reddish-brown and yellowish indurated plaques with pancytopenia and paraproteinemia

Department of Dermatology, Deen Dayal Upadhyay Hospital, New Delhi, India
Yashoda Hospital and Research Centre, Ghaziabad, Uttar Pradesh, India
Corresponding author: Dr. Anup Kumar Tiwary, D 302, Jeevan Ashray Apartment, C 58/08, Sector 62, Noida, Uttar Pradesh, India. anup07tunnu07@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Makkar R, Dixit A, Tiwary AK. Multiple reddish-brown and yellowish indurated plaques with pancytopenia and paraproteinemia. Indian J Dermatol Venereol Leprol, doi: 10.25259/IJDVL_425_2021

A 52-year-old female presented in outpatient department of dermatology in Deen Dayal Upadhyay Hospital, New Delhi, with a solitary ulcer on the right leg for two months and multiple, asymptomatic, elevated, slowly progressive skin lesions on face, extremities and trunk for about three years. Physical examination revealed multiple, bilaterally symmetrical, yellowish and reddish-brown plaques on infraorbital region [Figure 1], left arm, left forearm, right infra-axillary area and calves. There was a well-defined, painful, deep ulcer of 12.5 cm × 7.5 cm size on lower third of the right leg.

Figure 1:: Yellowish and reddish-brown plaques on infraorbital region

Systemic examination disclosed moderate splenomegaly. Skeletal survey showed punched-out lytic lesions on skull [Figure 2]. Routine laboratory investigations showed pancytopenia (haemoglobin 7.1 g/dl, total leucocyte count 3640/μl and platelet count 109/μl), raised erythrocyte sedimentation rate (120 mm/h), slightly elevated total serum protein level (8.60 g/dl) and hypoalbuminemia (2.94 g/dl). Serum protein electrophoresis showed M spike with hyper-gamma-globulinaemia (3.53 g/dl) along with highly raised beta-2-microglobulin level (10,347 ng/ml). Histopathology of truncal plaque demonstrated pandermal necrobiosis alternating with xanthogranulomatous infiltrate composed of numerous, large, foreign body, bizarre, angulated giant cells as well as Touton giant cells admixed with lymphocytes, histiocytes and sparse eosinophils. Focally, cholesterol clefts were also noted [Figure 3]. Thus, it was diagnosed as a case of necrobiotic xanthogranuloma associated with multiple myeloma.

Figure 2:: Skull X-ray showing lytic lesions
Figure 3:: Necrobiosis (black stars), Touton giant cells (black arrows), large foreign body giant cells (yellow arrow), angulated bizarre giant cells (red arrow) and cholesterol clefts (green arrow) (H & E, ×200)

Necrobiotic xanthogranuloma (NXG) is a rare type of non-Langerhans cell histiocytosis which is commonly associated with monoclonal gammopathy; but multiple myeloma has been reported in only about 10% of necrobiotic xanthogranuloma.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


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