Mycosis Fungoides in Elderly Adults—A Diagnostic Challenge

To the Editor: A 73-year-old Chinese woman complained of slowly progressive patchy scalp itchiness and redness associated with hair loss for longer than 10 years. She had seen many doctors, including dermatologists, and had been diagnosed with scalp dermatitis and psoriasis and given multiple courses of topical corticosteroids and tar shampoo with mild improvement. Scalp biopsy in February 2012 was compatible with psoriasis. She later developed a left breast nodule with erosion, worsening scalp condition despite good drug adherence, and multiple ill-defined erythematous patches on her limbs and trunk for 1 month in May 2012. Incisional biopsy of the nodule showed acute inflammation, and ultrasound and mammogram of her left breast reported benign findings. Regular wound dressing and antibiotics were initiated for presumably infective mastitis, but her condition continued to deteriorate, with a repeat biopsy showing a dense infiltration of small and medium-sized lymphoid cells throughout the dermis, extending to the subcutaneous layer. These cells were predominantly CD3-positive (T-cells) with retention of CD5, some loss of CD2, and prominent loss of CD7 (signifying immaturity). Lymphoid disease was suspected, so biopsies were repeated in the breast and thigh and revealed isolated single-haloed lymphocytes and groups of lymphocytes in the epidermis. Early Pautrier microabscesses, epidermotropism, and clonal T-cell receptor gene rearrangements were present, confirming the diagnosis of mycosis fungoides (MF). A staging positron emission tomography–computed tomography scan showed diffuse skin thickening and multicompartmental hypermetabolic lymph nodes in the right cervical, left axillary, and bilateral inguinal regions. Her bone marrow was not involved. She received 10 cycles of alemtuzumab, with initially good clinical response of her skin, but treatment was stopped in November 2012 because of pneumonia and reinitiated 6 months later. In July 2013, she relapsed while on alemtuzumab, presenting with a fungating tumor in her anterior abdomen (Figure 1A). A cycle of cisplatin, gemcitabine, ifosfamide, etoposide, and l-asparaginase was given, with prompt improvement (Figure 1B). She was subsequently discharged after a course of rehabilitation care.