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Carcinoma erysipeloides: An unusual presentation mimicking radiation dermatitis

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Carcinoma erysipeloides: An unusual presentation mimicking radiation dermatitis
Anil Gugle1, Vijay Malpathak2, Vijay Zawar1, Milind Deshmukh1, Rahul Kote1
Dermatology Online Journal 14 (2): 26

1. Department of Dermatology, NDMVPS Medical College and Research Centre, Nashik, Maharashtra State, India.
2. Department of Surgery, NDMVPS Medical College and Research, Centre Nashik, Maharashtra State, India

A 40-year-old woman was diagnosed in December 1999 with stage-II invasive ductal carcinoma of left breast. She underwent modified radical mastectomy followed by chemotherapy with methotrexate, 5-fluorouracil, and cyclophosphamide. She developed a local recurrence in November 2000 for which she was given external beam cobalt radiotherapy. While she was receiving the radiotherapy, she was referred to our department for sudden onset of tender, progressive erythematous plaque at the operated site, with a presumptive diagnosis of radiation dermatitis.

Figure 1Figure 2

On examination, she was afebrile and did not have a toxic appearance. She had a warm, slightly tender, erythematous sharply demarcated plaque with raised borders and irregular margins on her left pectoral area. There was crusting and erosion in the center of the plaque.

A few erythematous nodules surrounded the plaque (Figs. 1 and 2). Her investigations including hemogram, blood sugar, urinalysis, liver and kidney function tests, HIV antibodies, were all within normal limits or negative. Gram stain and the culture from the center of the lesion did not show any micro-organisms. Chest X-ray and abdominal ultrasound were unremarkable. A course of broad-spectrum antibiotics, analgesics, antihistamines, and topical steroids failed to clear the plaque.

Skin biopsy revealed flattened epidermis, dermis and subcutis showing diffuse infiltration mainly composed of tumor cells predominantly arranged on cords, strands, and acini. The tumor cells showed large, darkly staining hyperchromatic nuclei with indistinct nucleoli and abundant eosinophilic cytoplasm. There was no histological evidence of radiation-induced damage.

Cutaneous metastasis from the breast carcinoma may present with different morphological variants including nodule, plaque, annular, ulcerative, vesicular, keloidal[1], sclerodermoid[2], zosteriform[3], pigmented melanoma-like[4], cictricial, carcinoma en curasse, pagetoid[5], telangiectatic [6], and carcinoma erysipeloides (CE) [7].

Carcinoma erysipeloides constitutes about 1 percent of metastases from breast cancer. It is clinically characterized as a sharply defined inflammatory plaque thus simulating erysipelas. These metastases suggest rapid spread of tumor cells along subepidermal lymphatic vessels, thus resulting into lymphatic blockage, erythema, and vesicles [7]. Carcinoma erysipeloides may be a presenting manifestation of malignancy from breast or rarely from other organs and it is often considered to be a marker of tumor recurrence [7]. Carcinoma erysipeloides suggests a grave prognosis as there is likelihood of disseminated metastasis and could rapidly be fatal as happened in our case.

Carcinoma erysipeloides is a rarity in clinical practice and may be easily overlooked [10]. It is important to recognize this rare variant of cutaneous metastasis to avoid delay in accurate diagnosis so that further therapeutic intervention could be done wherever possible. Clinical regression may be seen in CE with anticancer therapy [11]. Our case also illustrates that CE could be misdiagnosed as radiation dermatitis.

Acknowldgment: We thank our ex-resident Dr. Piyush Thorat for his technical support in completing this manuscript.


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