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A case of invisible leukemic cutaneous T cell lymphoma with a regulatory T cell clone

A 63-year-old, healthy, asymptomatic Caucasian male was referred for mycosis fungoides (MF) found incidentally on histologic examination of benign acrochordons. He had tinea unguium and facial erythema of the face and neck in a photodistribution attributed to rosacea. No clinical lesions of MF or pruritus were present (Fig. 1). Multiple benign lesions including acrochordons, seborrheic keratoses, one cyst, melanocytic and neuroma contained superficial perivascular lymphocytic infiltrates without papillary fibrosis (Fig. 2a). Epidermotropism of lymphocytes with large hyperchromatic nuclei and Pautrier’s microabscesses were present (Fig. 2b, c). The infiltrate was predominantly CD4 over CD8 with loss of CD7 in the dermis and epidermal T cells (Fig. 2c, d). A flesh-colored papule was removed and was found to contain a well1111 Figure 1 Mild erythema of the face and the V of the neck, sparing the lower orbit.