Leg ulcer in a patient associated with hydroxyurea therapy

Hydroxyurea is a hydroxylated derivate of urea commonly used in the treatment of various hematologic disorders. Cutaneous side-effects such as alopecia, diffuse hyperpigmentation, scaling, poikiloderma, atrophy of the skin and subcutaneous tissues or nail changes can develop after long-term treatment with hydroxyurea. Painful leg ulcers in association with hydroxyurea have only rarely been reported. We present a report of a 52-year-old patient with essential thrombocythemia suffering from painful leg ulcers 3 years after starting therapy with hydroxyurea. We decided to treat the leg ulcers following a modern phase-adapted wound-healing strategy and continued hydroxyurea therapy until complete healing of the ulcers. In conclusion, cutaneous ulceration of the leg is one adverse effect in patients with essential thrombocythemia during hydroxyurea therapy. Healing does not necessarily require discontinuation of the drug. Therefore, therapists should first optimize a conservative and systematic wound-healing strategy. If these interventions fail, discontinuation of hydroxyurea therapy is advisable.     

原发性皮肤弥漫大B细胞淋巴瘤(腿型)3例

 报道3例原发性皮肤弥漫大B细胞淋巴瘤(腿型)。患者2女1男,年龄分别为77、57和77岁,分别表现为下肢、上肢及背部单发的无痛性肿块。皮损组织病理表现为真皮弥漫浸润的肿瘤细胞,体积大,异型性明显;免疫组化显示肿瘤细胞表达CD79a及Mum-1,而Bcl-6及Bcl-2呈阳性或阴性。诊断为原发性皮肤弥漫大B细胞淋巴瘤(腿型)。3例患者经过利妥昔单抗联合化疗后临床症状完全缓解,其中1例发生皮肤外扩散。     

Case of insulin edema occurring during intensive insulin therapy after bone marrow transplantation

A 50-year-old female patient, who had had a long-term history of myelodysplastic syndrome and type II diabetes mellitus, had developed acute myelogenous leukemia and received allogeneic bone marrow transplantation (BMT). She was being treated with tacrolimus, methotrexate and prednisolone for prophylaxis and treatment of graft-versus-host disease, and with intensive insulin therapy for better glycemic control. The patient suddenly developed marked leg edema at 27 days after starting intensive insulin therapy (on day 40 after BMT) without coexistence or exacerbation of apparent causes such as renal failure, cardiac dysfunction or leg thrombosis around the onset of leg edema. Interestingly, the leg edema regressed soon after daytime hyperglycemia and intensive insulin therapy were performed. Histopathological examination revealed slight dermal edema and small bullae with little inflammatory infiltration but no signs of autoimmune blistering diseases or vasculitis. These findings indicate that the present case may be considered a form of so-called insulin edema occurring during intensive insulin therapy after BMT.     

大疱性类天疱疮并发原发性皮肤弥漫性大B细胞淋巴瘤

报告1例大疱性类天疱疮并发原发性皮肤弥漫性大B细胞淋巴瘤.患者男,80岁.全身水肿性红斑伴水疱、大疱,诊断为大疱性类天疱疮.在发病7个月后,右胫前出现多个暗紫红色结节,逐渐增多、增大,并扩展至右股内侧和背部.皮损组织病理检查示真皮全层及皮下脂肪小叶弥漫致密的淋巴细胞浸润,可见多数淋巴细胞体积增大,形态不规则,核大深染,可见核分裂相.免疫组化染色:CD20( ),bcl-2( ),bcl-6( ).诊断:原发性皮肤弥漫性大B细胞淋巴瘤.在肿瘤出现后1个月,患者大疱性类天疱疮的病情出现反复,通过CHOP方案治疗,病情明显好转.     

Removal of dermal edema with class I and II compression stockings in patients with lipodermatosclerosis

Background: Lipodermatosclerosis is a sequela of deep venous insufficiency and a risk factor for the occurrence of venous leg ulceration. Medical compression stockings facilitate leg ulcer healing and prevent occurrence of ulcers resulting from removal of edema. Although the exact level of compression necessary for removal of dermal edema in patients with deep venous insufficiency has not been established, garments providing high compressive values of 30 to 40 mm Hg have been recommended. Dermal edema can be visualized by high-frequency ultrasonography. Objective: We used ultrasound imaging to study whether a lower level of compression (class I 18 to 26 mm Hg vs class II 26 to 36 mm Hg) is effective in removal of dermal edema. This question is important because the use of hosiery with a lower compression class would enhance compliance and enable treatment of patients with mixed arteriovenous disease. Methods: In 11 patients skin images were obtained with 20 MHz ultrasound from the malleolar region in lipodermatosclerotic skin and corresponding normal skin of the contralateral leg. The ratio of low echogenic pixel number to total pixel number (LEP/TP), which correlates with dermal water, was measured before and after 5 days of applied compression in two treatment courses where classes of compression were switched randomly. Ankle circumference was also measured. Results: We found that LEP/TP was 33% higher in lipodermatosclerotic skin than in the matched normal skin indicating presence of skin edema. Application of class I and II compressive hosiery resulted in LEP/TP decrease by 17% (95% confidence interval, 0.07 to 0.26) and 14% (95% confidence interval, 0.04 to 0.21), respectively, suggestive of dermal edema reduction. No statistically significant difference in efficacy of dermal edema removal between class I and II was found. No changes in ankle circumference after application of both classes of compression was observed. Conclusion: Application of light and moderate compression results in a partial edema removal from the dermis in lipodermatosclerosis in the absence of measurable reduction in leg circumference. Class I compression is as effective as class II for elimination of dermal edema. These data indicate that light compression may be a useful modality for patients with deep venous insufficiency and lipodermatosclerosis who are not eligible for treatment with garments having higher compressive forces. (J Am Acad Dermatol 1998;39:966-70.)     

Papular Mucinosis Associated with Systemic Lupus Erythematosus

Papulonodular mucinosis (PNM) is a rare variant of lupus erythematosus (LE) eruptions, and PNM is characterized histologically by diffuse dermal mucin without any typical epidermal inflammatory changes. We herein describe a case of papular mucinosis that was characterized by several erythematous papules on the lower back of a 32-year-old man with systemic LE. It is interesting that he didn''t display any other skin manifestations of LE such as malar rash, discoid rash and photosensitivity during the previous 2 years. He achieved remission of his PNM without recurrence after 5 months treatment with topical steroids, in addition to receiving systemic antimalarials and steroids.     

Tumefactive lipedema with pseudoxanthoma elasticum-like microscopic changes

BACKGROUND: Lipedema is a condition characterized by diffuse, bilaterally symmetrical, painful swelling of the legs and buttocks. Microscopically, there are dermal and septal edema, adipocyte degeneration, and numerous mast cells, features held in common with lipedematous alopecia. CASE REPORT: We present the case of a 60-year-old woman with a long history of bilateral leg masses with microscopic features of lipedema. In addition, elastic-fiber changes typical of pseudoxanthoma elasticum (PXE) were discovered within the subcutaneous septa in three separate specimens obtained from an affected extremity. The patient did not have other clinical findings of PXE, although there was a history of both hypertension and congestive heart failure. CONCLUSION: This tumefactive presentation of lipedema has not been previously described. Regarding the elastic-tissue abnormalities, the patient could have either a subclinical form of PXE, perhaps predisposing to lipedema, or secondary elastic-tissue changes resulting from the massive edema. If the latter is the case, then this could represent an unusual manifestation of localized acquired cutaneous PXE (calcific elastosis).     

Post‐erysipela panniculitis ossificans of the lower leg treated with pentoxifylline

We report the case of a female patient who developed a firm, wooden‐like, nonpitting edema of the left lower leg after a dermo‐hypodermitis. The clinical picture was accompanied by intense pain, strongly impacting the patient's quality of life. A soft‐tissue ultrasound demonstrated several millimetric hyperechoic linear lesions whose histopathological examination was conclusive for panniculitis ossificans. A conservative medical management with compression stockings associated with pentoxifylline 800 mg/day was prescribed with improvement of the edema and, in particular, a good pain control. To date, after a 2‐year therapy with pentoxifylline, the leg wooden‐like edema has substantially improved, despite the persistence of the well‐known foci of ossification, and the pain has resolved, conditioning a substantial improvement of the patient's quality of life. No side effect has been observed during the routine follow up. Although there is no unanimous opinion in the literature about the effect of pentoxifylline on bone formation and osteogenic differentiation, pentoxifylline treatment proved to be beneficial in our patient both for the heterotopic ossification process and the pain control. We collected some of the data in literature about pentoxifylline effects and advanced some hypotheses to explain our results. Finally, we suggest that an anti‐inflammatory and vasodilators drug such as pentoxifylline could be a possible alternative in heterotopic ossification disorders.     

Macular Pigmentation Following Low Fluence Nd:YAG Laser Procedure at Sites of Gold Thread Implantation

Use of gold thread rejuvenation and Q-switched low fluence neodymium-doped yttrium aluminum garnet (Nd:YAG) laser treatments have become a recent fashion trend in the skin care industry, and are frequently used for skin care management. Although the efficacy and side effects of the individual procedures have been well documented, the combined effects of the two treatments have not been reported. We describe a unique case of macular pigmentation on the face, resulting from the low fluence (3 J/cm²) Nd:YAG laser procedure solely at the sites of gold thread implantation. A skin biopsy revealed rod-shaped foreign material and tiny golden colored granules surrounded by minor inflammatory infiltrates. Therefore, the use of a Nd:YAG laser at a specific wavelength (potentially 1064 nm) may trigger macular pigmentation when in contact with pre-implanted gold threads by as yet unknown mechanism.     

The histomorphologic spectrum of primary cutaneous diffuse large B-cell lymphoma: a study of 79 cases

Primary cutaneous large B-cell lymphomas (PCLBCL) have historically been a matter of debate in the literature. The 2005 World Health Organization-European Organization for Research and Treatment of Cancer (WHO-EORTC) classification scheme segregated cutaneous B-cell lymphomas into 3 groups: primary cutaneous marginal zone B-cell lymphoma, primary cutaneous follicle center cell lymphoma, and primary cutaneous diffuse large B-cell lymphoma (PCDLBCL), "leg type" (PCDLBCL-LT). Additionally, the WHO-EORTC classification scheme utilized the term PCLBCL "other" not otherwise specified (NOS) type for rare cases of PCLBCL not belonging to either the "leg type" or the primary cutaneous follicle center cell lymphoma group. In this study, we retrospectively assessed the histomorphologic features of 79 cases of PCDLBCLs, including those of "leg type" and "other" NOS type, to further categorize the histologic spectrum of these unusual cutaneous neoplasms. The histologic diagnosis of PCLBCL usually poses little diagnostic difficulty; however, some cases may adopt unusual or unfamiliar appearances mimicking other lymphoproliferative disorders or other malignant neoplasms. Seventy-nine cases, occurring in 37 men and 42 women, aged 34-94 years, were analyzed. Fifty-three cases were classified as "leg type" and 26 cases were classified as "other" NOS type using the WHO-EORTC classification. Of the 53 cases classified as "leg type," 33 were women and 20 were men; of the 26 cases of "other" NOS type, 9 were women and 17 were men. In the "leg type" category, 31 cases were located on the lower extremities, 5 cases on the face, 5 cases on the arm, 3 cases on the chest, 2 cases on the shoulder, 2 cases on the back, 1 case on the trunk, 1 case on the buttock, 1 case on the supraclavicular area, 1 case on the head, and 1 case on the flank. Of the "other" NOS type category, 8 cases were located on the face, 5 cases on the shoulder, 3 cases on the head, 2 cases on the abdomen, 2 cases on the chest, 1 case on the trunk, 1 on the vulva, 1 on the axilla, 1 on the back, 1 on the neck, and 1 on the hip. Most cases assessed showed the classic morphologic appearance of PCDLBCL, but cases mimicking Burkitt lymphoma (starry-sky pattern), natural killer-cell (NK) lymphoma, mycosis fungoides (epidermotropism), low-grade B-cell lymphomas, epithelial malignancies, and Merkel cell carcinoma were encountered in this series. The high frequency of these rare histologic patterns can be explained by a bias associated with consultation practice. Careful histologic examination and immunohistochemical stains were used to establish the correct diagnosis. The differential diagnosis of PCDLBCL is broad and difficult to define histologically. Knowledge of these rare histologic variants is necessary to avoid misinterpretation of these cases as nonlymphoid malignancies.     

Linfoma cutáneo primario difuso de células grandes-tipo pierna con regresión espontánea

Primary cutaneous diffuse large B-cell lymphoma, leg type (PCLBCL LT) accounts for approximately 20% of all primary cutaneous B-cell lymphomas and tends to present as infiltrated nodules, tumors, and plaques on the legs in the elderly. Unlike other primary cutaneous large B-cell lymphomas, it has a poor prognosis and tends to require treatment with systemic chemotherapy.We present the case of an 82-year-old patient with a 1-year history of nodules and plaques on her right leg. Biopsy led to a diagnosis of PCLBCL LT and the lesions resolved without treatment within 1 month of the first visit. This is an atypical course of PCLBCL LT and we believe that it is the first such case to be reported in the literature.     

Measurement of croton oil induced rabbit ear swelling and evaluation of anti-inflammatory agents with a standard low pressure caliper

Background/aims: Carbobenzoxy-phenylalanyl-methionine (CBZ-Phe-Met), a known inhibitor of the chemotactic peptide N-formyl-methionyl-leucyl-phenylalanine (fMLP) in vitro, has not been evaluated as a topical anti-inflammatory agent in vivo. In order to measure the effect of CBZ-phe-met, one needs a repeat-able, quantitative, easily obtainable standard measurement of the edema formation. In this study, a caliper designed for measuring soft materials was used to evaluate the edema, induced by croton oil on rabbit ears, as well as the effects of CBZ-phe-met.
Methods: The model used in this study was croton-induced inflammation on rabbit ears. A caliper for measuring soft materials (European standard DIN 863 part 3, manufactured by TESA Ltd., Renens, Switzerland) was used to evaluate the edema, which is part of the inflammatory effect. The action of CBZ-phe-met and two other anti-inflammatory agents; hydrocortisone and Na-ibuprofen, were compared.
Results: CBZ-phe-met 1-5% was found to reduce the edema on rabbit ears induced by croton oil by 15 to 93%. 5% CBZ-phe-met was found to be as effective as 5% Na-ibuprofen and 0.1% hydrocortisone.
Conclusion: The caliper for soft materials was found to be suitable for measuring the edema induced by croton-oil, as well as the reducing edema due to anti-inflammatory treatment. It was also found that CBZ-phe-met is a potent topical anti-inflammatory agent in the croton-oil-induced inflammatory model. This may indicate a new approach in the treatment of inflammation.     

AA amyloidosis: a little-known complication of chronic leg ulcer

INTRODUCTION: AA amyloidosis, secondary to inflammatory chronic diseases like rheumatoid arthritis, is often complicated by renal failure. Chronic inflammatory dermatoses constitute rare causes of AA amyloidosis. CASE-REPORT: We describe two cases of AA amyloidosis discovered after renal failure in patients presenting leg ulcers for several years. AL amyloidosis was suspected in both cases because of a history of monoclonal gammopathy in one patient and of plasmocytoma in the other. The diagnosis of AA amyloidosis was confirmed on renal histology through the detection of AA antibodies in amyloid deposits. No extrarenal amyloidosis was seen in either patient and there were no inflammatory diseases other than chronic leg ulcers. DISCUSSION: AA amyloidosis is caused by serum amyloid protein A (SAA), a reactive inflammatory protein. AA amyloidosis is thus caused by chronic inflammatory diseases, but only rarely by cutaneous inflammatory diseases. To our knowledge, the literature contains only seven other published cases of AA amyloidosis secondary to chronic leg ulcers. A review of the literature does not indicate whether cure of ulcers has any effect on the accompanying renal failure. We imagine that AA amyloidosis secondary to leg ulcer is in fact under-diagnosed. However, since the first specific treatment for AA amyloidosis is currently being evaluated by the Food and Drug Administration, it is essential that this serious complication of chronic leg ulcers be widely recognised.     

Melkersson-Rosenthal Syndrome—A Challenge for Dermatologists to Participate in the Field of Oral Medicine

Melkersson-Rosenthal syndrome (MRS) is a neuro-muco-cutaneous disorder involving remittently both the oro-facial innervation and muco-cutaneous tissues in a pathosis of complex origin characterized by recurrent edema, facial or other palsies, and nerval dysfunctions frequently assoiciated with plicated tongue. Biopsies taken from the edematous tissues often reveal a temporary pattern of moderate epitheloid granulomatous inflammation scattered scarcely within remarkable tissue edema. However, this histological pattern is not a prerequisite for the diagnosis of MRS. The disease usually runs an intermittent and unpredictable course over years or decades and may have, if the edemas involve the tongue or the central nervous system, an ambiguous outcome. Greatly disfiguring oro-facial swellings often result from secondary persistence of the primarily recurrent edemas. A classification on grounds of different ‘major’ and ‘minor signs’ of MRS is proposed in the present paper. In recent years, novel therapeutic approaches involving either oral clofazimine or laser beam acupuncture (according to the principles of traditional Chinese medicine) have proven to be successful in some cases of MRS. Dermatology could play a larger role in oral medicine by taking diseases such as MRS into account in studies among specialties dealing with oro-facial pathoses.     

Morbihan病一例

患者，男，76岁。面部红斑、肿胀1年。皮肤科查体：中上面部对称性、弥漫性分布的红斑及非凹陷性水肿，皮损边界不清。皮损组织病理学示表皮大致正常，真皮浅层血管周围淋巴细胞为主的炎性细胞浸润。结合临床特点及组织病理学及特殊染色表现诊断为Morbihan病，目前长期随访中。     

Laser use for cutaneous vascular alterations of cosmetic interest

In 1983, selective photothermolysis dramatically transformed vascular surgery, reducing the adverse effects and increasing its efficacy. As a result, laser surgery is now considered the gold standard treatment for many congenital and acquired skin vascular disorders. In this paper, the authors analyze the main laser sources for vascular surgery, the general parameters regarding laser-tissue interactions that can influence the treatment (such as hemodynamic features, anatomical areas, vessel depth, and diameters), and other aspects important for a good laser practice. Afterward, the main indications for laser treatment in vascular cutaneous disorders are discussed, with particular reference to port-wine stain, hemangioma, facial telangiectasia, rosacea, spider angioma, venous lake, varicose leg veins, and leg telangiectasias.     

Primary cutaneous B‐cell lymphoma in Nottinghamshire U.K.: prognosis of subtypes defined in the WHO‐EORTC classification

Background Primary cutaneous B‐cell lymphomas (PCBCL), with the exception of large B‐cell lymphoma of leg type and intravascular large B‐cell lymphoma, are associated with an excellent prognosis. These lymphomas have become much better understood in recent years leading to the publication in 2005 of the World Health Organization–European Organisation for Research and Treatment of Cancer classification. Objectives To determine the relative frequency of occurrence of subtypes of PCBCL in a defined population, and the survival of patients with these subtypes. Methods During the period 1987–2009, 61 consecutive patients with PCBCL were identified from the Nottingham Lymphoma Registry (population 1·1 million). After histological review, the number of patients with each subtype was as follows: marginal zone, 18; follicle centre, 14; diffuse large B cell, leg type, 16; diffuse large B cell, other sites, 12; and intravascular large B cell, one. Results The 5‐ and 10‐year lymphoma‐specific survival for patients with marginal zone lymphoma was 100%. The only patient with intravascular large B‐cell lymphoma died from widespread disease in spite of chemotherapy. The 4‐year lymphoma‐specific survival for follicle centre cell lymphoma was 90%. Patients with the other subtypes had the following 5‐year lymphoma‐specific survival rates: diffuse large B cell, leg type, 61% and diffuse large B cell, other, 40%. The median age at diagnosis for patients with diffuse large B‐cell lymphoma, leg type was 82 years and as a consequence the 5‐year overall survival was only 15%. There was a 3·4‐fold increase in the incidence of PCBCL from the period 1987–1997 to the period 1998–2009. Conclusions PCBCL is a rare disease (incidence around three per million population per year). It is, in our view, essential that it is diagnosed by a pathologist with an interest in cutaneous lymphoma and that the very different prognosis of the individual subtypes is appreciated by the treating clinician.     

Treatment for cutaneous arteritis patients with mononeuritis multiplex and elevated C‐reactive protein

Cutaneous arteritis (cutaneous polyarteritis nodosa, CA) is a necrotizing vasculitis of arteries within the skin. CA is a new classification under single‐organ vasculitis, as adopted by the 2012 Chapel Hill consensus conference (CHCC 2012). Some patients originally diagnosed as having CA could develop additional disease manifestations that warrant reclassifying as systemic polyarteritis nodosa (PAN) according to the CHCC 2012. We retrospectively investigated 101 patients with CA seen at our department between 2003 and 2012. There was a significantly higher frequency of inflammatory plaques and leg edema in CA patients with elevated C‐reactive protein (CRP) compared to CA patients with normal CRP. Similarly, there were significant differences in the incidence of arthralgia and mononeuritis multiplex between the two patient groups. We found significantly positive correlations between CRP and creatinine titers in serum in all 101 CA patients. Prednisolone was administrated in a significantly greater percentage of patients with elevated CRP compared to patients with normal CRP. Repeated i.v. cyclophosphamide pulse therapy (IV‐CY) with prednisolone therapy at an early stage resulted in complete resolution without adverse effects or severe complications. We regard inflammatory plaques and leg edema with elevated serum CRP as an indication of a more severe condition, and treated them effectively with prednisolone. Assuming mononeuritis multiplex and/or arthritis exist with elevated CRP, we propose that earlier treatment by IV‐CY with prednisolone should be indicated for CA patients who demonstrate these more severe manifestations to prevent progression to PAN.     

Subcutaneous inflammatory edema induced by MINE chemotherapy

BACKGROUND: The MINE regimen (mitoguazone, ifosfamide, vinorelbine and etoposide) is a salvage chemotherapy for relapsed and refractory Hodgkin's disease. CASE REPORTS: We report the cases of a 16-year-old girl and a 17-year-old boy who had Hodgkin's disease and developed painful and massive subcutaneous inflammatory edema after MINE chemotherapy. Morphine was unable to control pain leading to major functional disability of joint movement. One patient had an elevated creatine kinase level, hypoalbuminemia, hypodermic and muscular edema at magnetic resonance imaging and diffuse hemorrhagic hypodermic edema at skin biopsy. The other patient was found to have only hypoalbuminemia. The clinical course was favorable in both cases within a few weeks, but with recurrent episodes of pain and localized areas of fat necrosis five months later in one case. DISCUSSION: This side effect of MINE chemotherapy - subcutaneous inflammatory edema, myalgia and skin pain - has not been described previously for the different components of the regimen. Three clinicopathological hypotheses could be put forward: capillary leak syndrome, panniculitis, toxic fasciitis. The causal drug remains undetermined, but the most likely would be vinorelbine because of the chronology of the eruptions during the first and last days of chemotherapy and because of the known vascular toxicity of vinorelbine which could explain a capillary leak syndrome.     

Concurrent Sweet's syndrome and leukemia cutis in patients with myeloid disorders

A 74-year-old woman with chronic auricular fibrillation, arterial hypertension, hypercholesterolemia, ischemic cardiopathy, and peripheral arteriopathy presented with purpuric lesions on the lower limbs (Fig. 1) and, to a lesser extent, on the anterior area of the chest. The mucous membranes were not affected. In 1989, she was diagnosed with anemia that evolved until 1998, when a bone marrow biopsy revealed a myelodysplastic syndrome unclassified in French-American-British Group (FAB). The patient has required periodic transfusions since February 1999. A skin biopsy of the purpuric lesions revealed a leukocytoclastic vasculitis; the lesions cleared with topical corticosteroid treatment. In May 1999, the patient presented with inflammatory and painful lesions localized on the vulva (Fig. 2), which had evolved over several days, without fever. No lesions were observed in other locations. A cutaneous biopsy showed an intense dermal edema and a diffuse and polymorphous dermal infiltrate involving the follicular structures. Exocytosis, spongiosis, and mucin deposits, demonstrated by Alcian blue stain, were observed in the follicular epithelium. Mature neutrophils were predominant in the dermal infiltrate, but a small number of eosinophils and immature cells were also present (Fig. 3). The myelogenous origin of the immature lining cells was further confirmed by positive staining of intracytoplasmic granules with naphthol-ASD chloroacetate sterase (Leder's stain). Vasculitis was not observed. Routine laboratory tests revealed 3030 leukocytes/mm(3) (60% neutrophils), a hemoglobin level of 8.4 g/dL, and 92,000 platelets/mm(3). Treatment with 30 mg/day of prednisone was started, and the lesions cleared slowly within 4 weeks. A new bone marrow biopsy in September 1999 showed a similar appearance to that taken in 1998. The patient died in January 2000 as a result of pneumonia with cardiac and respiratory failure. A 66-year-old man presented with a febrile syndrome that had evolved over 5 days, and painful and pruritic cutaneous lesions on the face and posterior neck (Fig. 4). Three months before, the patient was diagnosed with chronic myelogenous leukemia in acceleration phase. Examination revealed an edematous and erythematous face with pustular lesions on the surface, also involving the neck and the upper part of the back. The histopathologic examination revealed an intense edema and abscesses in the dermis. The infiltrate of these lesions was composed of mature neutrophils with the presence of abundant immature cells with a myelogenous aspect (Fig. 5). Analytical studies revealed 26,130 leukocytes/mm(3) (42% blasts). No specific treatment for Sweet's syndrome was administered and the lesions showed an improvement within 5 days. Eight days after admission, the patient died as a result of acute hemorrhage, before treatment for leukemia was initiated.