NOT ALL SWELLING WITH REDNESS AND BAD SMELLY DISACHRGE IS NECESSARLY AN ABSCESS Al-Sharabati, Mohamed Barakat, MD, Pathologist Rasheed, Osaid, RN, CNS. Al-Ahli Hospital ( Dr. Hafiz A-Nabi CE Center ), Al-Makassed Hospitals Palestine 2009

General Problem A 22 yrs old female recently gave birth at a peripheral hospital. Since early pregnancy she felt a small nodule at the left inguinal region. The nodule increased in size and was associated with genital progressive swelling with redness and very bad smelly discharge, treated with ABs without improvement. She was discharged home after giving birth. Drainage of the mass in an outpatient clinic was done for several weeks, accompanied by ABs.

Clinical History The patient was admitted to Al-Ahli Hospital SW, few weeks after delivery. The CBC showed leukocytosis ( 21,100 ) with 86% Neutrophil count. Provisional Dx was Inguinal Lympho Granuloma ?, Vulval tumor ?, Chronic Abscess ?

Cont’d An incisional biopsy was taken and sent for the pathology department at Al-Ahli Hospital.

Histopathological Examination

Dx: LARGE CELL LYMPHOMA

Confirmation and Immuno Stain The tumor cells are positive for EMA, MIB-1, CD30, and ALK protein ( Anaplastic Lymphoma Kinase ). Focally positive for CD3. Negative for CD2, and CD10.

Immunostain CD30 +ve

Immunostain ALK Protein +ve

Immunostain EMA +ve

Immunostain CD3 +ve

Immunostain CD2 -ve

Final Diagnosis Cutaneous Anaplastic Large cell lymphoma, CD30 & ALK Positive.

Current Status The patient is completely cured, 2 years after the appearance of the first lesion and 1 year after chemotherapy ( M.A.C.O.P-B ).

Lt Thigh Inguinal Region Surgical Scar

Discussion C-ALCL affects mainly adults with an M:F ratio of 2- 3:1. ( Bekkenk et al, 2000 ) Most patients present with solitary cutaneous tumor. Extra cutaneous dissemination occurs in 10% of cases, mainly LNs. ( Liu et al, 2003 ) Multifocal lesions in 20% of cases. ( WHO / EORTC Classification, 2005 ) ALK pos are diagnostic and favorable prognostic markers. ( Delsol et al, 2006 ) The prognosis is usually favorable with a 10-year disease-related survival exceeding 90%. ( Delsol et al, 2006 )

Conclusion Primary Cutaneous CD30+ Lyphoproliferative Disorders ( LPDs ). This group includes C-ALCL, LyP, and borderline cases. It is now generally accepted that C-ALCL and LyP form a spectrum of disease, and that histological criteria alone are often insufficient to differentiate between these two ends of this spectrum. ( Willemze et al, 2000 and WHO/EORTC Classification for CL, 2005 ) The clinical appearance and course are used as decisive criteria for the definite diagnosis and choice of treatment. ( WHO/EORTC Classification for CL, 2005 ) The term “ borderline case “ refers to cases in which, despite careful clinico-pathological correlation, a definite distinction between C- ALCL and LyP cannot be made. Clinical examination during further follow up will generally disclose whether the patient has C-ALCL or LyP. ( Bekkenk et al, 2000 )

Disease is of old and nothing about it has changed. It is WE who change when we learn to recognize what formerly was imperceptible. Jean Marie Charcot Physician, Salpetriere Hospital, Paris