2. SBE (sub-acute bacterial
endocarditis)
Emboli trapped at the capillary beds show as micro-
hemorrhages or infarcts.
3. Nail bed pathology
Differentiate from Hutchinson’s Sign for melanoma
Superficial Spreading: most Clubbing of nails can be seen in
common and seen on back and trunk. pachydermoperiostosis syndrome
Can become nodular (seen in lung cancer—
bronchogenic or alveolar cell
Nodular: vertical growth phase carcinoma
Bazex’s syndrome (yellow nails
Acrolentigenous: seen on digits
with violaceous color of skin) seen
and subungual areas, more common
in lung cancer
blacks
Terry’s Nails (ground glass
Lentigo Maligna: least common, appearance to nails) can be seen
usually on face or other actinic in CHF
exposure areas
4. Acute Leukemias (non-lymphoblastic)
Uncontrolled proliferation of hematopoietic cells with malignant
cells filling marrow and other tissue and with the reduced
production of erythrocytes, granulocytes and megakaryocytes,
anemia, infection and hemorrhage results.
80% incidence of ALL (acute lymphoblastic leukemia) in children
80% incidence of ANLL (acute non-lymphocytic leukemia) in
adults
Classification is via predominant neoplastic cell line
(lymphoblastic or non-lymphoblastic [myeloblastic/monocytic])
Sub-classified by the FAB (French/American/British) group
5. Acute Leukemias (non-lymphoblastic)
Etiologies include chromosomal damage from radiation, chemicals (e.g., benzene and alkylating
agents used in therapy), congenital diseases (e.g., Down’s syndrome), and chronic bone marrow
diseases (e.g., myeloid metaplasia), congenital predisposition, and congenital immunodeficiency
syndromes (e.g., ataxia-telangiectasia).
In acute leukemia, the uncontrolled proliferation of hematopoietic cells in the bone marrow and
peripheral blood eventually replace the marrow and invade other tissues and organs. The
manifestation of the disease results in diminished production of erythrocytes, granulocytes and
megakaryocytes with resulting anemia, infection and hemorrhage.
As the degree of marrow and other organ involvement progresses, symptoms of fatigue,
ecchymosis, buccal lesions and infection increase. Peri-rectal infections are often seen in ANLL
with skin and gum infiltrates seen an acute monocytic leukemia. Rheumatic symptoms occur
commonly with ALL, as well as lymphadenopathy and hepatosplenomegaly. Patients with ANLL
can have unusual masses in the soft tissue and nodal sites, as a precursor of overt marrow and
peripheral blood invasion and may be mistaken for lymphoma. These are called myeloblastomas.
6. Acute Leukemias (non-lymphoblastic)
Degree of organ or marrow
involvement will dictate the
types of lesions
Skin and gum infiltrates are
commonly seen in AML
(Candida albicans)
Leukemic infiltration of the
gums in AMOL
Peri-rectal infections are
frequent in ANLL
Joint swelling and bone pain
with rheumatic symptoms is
seen in ALL
7. Acute Leukemias (non-lymphoblastic)
AMOL lesion (1)
1
ANLL leukemia cutis
(2)
Leukemic infiltrates
at the eye (3)
Acute leukemia at
4
2
the anterior shin (4)
AML with petechial
3
hemorrhages (5)
5
8. Acute Leukemias (non-lymphoblastic)
• Sweet’s syndrome: acute febrile neutrophilic
dermatosis. Seen in AML or AMOL (acute monocytic
leukemia). Seen here in ANLL (acute non-lymphocytic
leukemia [1])
• Usually drug-induced or following a viral 3
illness in the young
• 10% incidence of underlying cancer, most
commonly myelocytic leukemia (1-3)
1
• Nonmyelocytic leukemia and lymphoma
have been reported (4)
• Other cutaneous presentations: 4
2
– Arm in AML (2)
– Leg in AML (3)
– Scalp in ANLL (4)
9. Acute Leukemias (non-lymphoblastic)
• Bone involvement: acute
leukemic infiltration with necrosis
marked by yellow opacification of the
marrow with surrounding hyperemic
tissue.
10. Acute Leukemias (non-lymphoblastic)
AML-induced Pseudomonas pyocyanea
•
infection at the foot and hand
• Streptococcal cellulitis at the neck and
face all induced by the neutropenia from
the prior chemotherapy for AML
12. Graft vs. Host Disease
• Acute leukemia therapy (allogenic
bone marrow transplant) can result in
morbidity/mortality. This is seen as a
range from papulosquamous eruptions
or desquamation of the skin, with the
palmar and plantar areas most
commonly involved, as in this patient
with AML
13. Chronic Leukemias
3
• CLL (chronic lymphocytic leukemia)
presenting as lymphadenopathy (1)
• CLL converting to DLCL (diffuse large cell
lymphoma) with trunk lesion which shows
B-immunoblastic type diffuse large cell
lymphoma or Richter’s syndrome (2) 4
1
• CLL-induced herpes zoster lesions (3) with
buccal infection with Candida albicans (4)
• CLL-induced pharyngeal tonsil
enlargement (5)
2
5
14. Chronic Leukemias
• CML can present with
hyperviscosity syndrome
and hepato-
splenomegaly. Note the
splenic infarct (white
spot at the surface of
the spleen
15. Lichen Planus
• Inflammatory, muccocutaneous condition with common
1
morphology
• Long-term oral mucosal lesions (1) have an increased
risk of developing squamous cell carcinoma. Same with
genital lesions.
• Causes include drug eruptions and HCV infection,
although most cases are idiopathic
• Treatment includes oral and topical steroids, Soriatane,
2
PUVA and possibly Dapsone and Plaquenil
• Usual presentation is a violaceous polygonal flat-top
papule (2) and plaque with white scales (Wickham’s
striae)
• Variations include:
– a hypertrophic version (3)
5
– Vesiculobullous (4) and actinic type (5)
variants 4
– Nail and subungual presentation
3
16. Internal Malignancies
• The most common benign Other diseases:
cutaneous lesions most likely to –Multiple eruptive seborrheic keratoses
be associated with internal
–Sweet’s syndrome
malignancy include:
–Erythroderma
1. Dermatomyositis
–Xanthoma
2. Acanthosis nigricans
–Pemphigus vulgaris
3. Necrotic migratory erythema
–Erythema gyratum repens
4. Herpes zoster
17. Dermatomyositis
• Associated with internal neoplasia with a •Diagnosis is a combination of muscle
27% incidence rate. abnormalities and characteristic heliotrope
rash (periorbital reddish-purple flush which
• Prevalence in women
predates the muscle weakness by weeks,
• Ovarian, breast, lung, stomach and colon
months or even years
cancers are most often seen in association
•A violaceous erythema appearing over the
with dermatomyositis with the cutaneous
knuckles, elbows and knees (Gottron’s sign)
presentation identical regardless of cancer with raised, flat-topped papules on the
type knuckles (Gottron’s papules)
• Polymyositis appears clinically as
dermatomyositis, but has none of the
increased cancer risks.
Heliotrope Rash
18. Acanthosis Nigicans
• Associated with GI
cancer (adenocarcinoma
is the most common)
• Also associated with
Diabetes Mellitus and
obesity
19. Necrotic Migratory Erythema
• Associated with α-cell
islet tumors, with 60%
malignant
(glucagonoma)
• Seen with Diabetes
Mellitus
• Glossitis also often seen
20. Herpes Zoster
• With disseminated,
severe and ulcerative
disease, may signal
cancer in 75% to 80%
of people
• Usual association is with
lymphoma and leukemia
21. Xanthoma Planum
• Has a high
association with
Multiple Myeloma
• No lipid dyscrasias
in these patients
22. Multiple Eruptive Seborrheic
Keratoses
•Most commonly associated with
• Benign neoplasms usually
adenocarcinoma of the stomach
• Abrupt onset associated with
•Others include leukemia,
underlying cancer is called the
mycosis fungoides, hepatoma
sign of Leser-Trélat
and carcinoma of lung and breast
23. Erythroderma
• Usually seen in psoriasis,
atopic dermatitis, drug-
induced allergic reactions
• 15% of cases are with
underlying malignant
disorders such as Sézary
syndrome or mycosis
fungoides
24. Pemphigus Vulgaris
• Autoimmune disease with
bullous lesions which rupture
leaving a denuded patch called
“Nikolsky’s sign”
• Can be associated with
thymoma and myasthenia
gravis
• Paraneoplastic pemphigus is
associated with cancer, most
commonly non-Hodgkin’s
lymphoma with 90% mortality
due to sepsis or respiratory
failure
25. Erythema Gyratum Repens
• Wood grain pattern in the
skin
• 90% associated with
internal cancer
• Most commonly lung
• Less commonly esophagus
and breast
26. Breast Cancer
• Cutaneous presentation seen
in 1% of patient population.
• Can be direct extension of the
tumor or of local or distant
metastasis
• Direct extension most common
with breast cancer and oral
cancer
27. Ovarian Cancer
• Malignant, cutaneous lesions
indicative of systemic cancer are
typically nodular with a firm
consistency and are red, plum-
colored or hyperpigmented
• Ulceration of the lesions suggest
an underlying cancer
28. Other Signs
• Flushing, usually evident in the face and upper chest, most commonly
accompanies carcinoid tumors of the intestine
• Palmar erythema, usually associated with advanced liver failure, may
also accompany primary or metastatic malignant liver disease
• Direct extension of breast cancer to the skin may be accompanied by
telangiectasia
• Purpuric lesions may be a manifestation of disseminated intravascular
coagulation induced by cancer. DIC can also cause acral gangrene in
foot and hand.
• Thrombophlebitis is usually migratory when associated with cancer
29. Gonococcal Septicemia
• Seen with Disseminated
Gonnococcal infection DGI
• Present with pyrexia,
polyarthralgias and skin lesions
which may be papular,
petechial, pustular, hemorrhagic
or necrotic and usually found on
the distal extremities
30. Syphilis
• Primary syphilis usually presents as a chancre 1
with bilateral inguinal adenopathy which may
persist for months
• Secondary syphilis presents with skin lesions
(1) which move from macules to papules and
pustular erosions with the palms and soles
often affected (2)
3
• Intertrigenous areas can manifest with
papules enlarging to moist lesions called
condyloma lata (3), which are highly
infectious
• Tertiary syphilis is neurosyphilis and presents
largely as changes in mentation, with
sensorium and autonomic deficit
(demyelination of posterior columns),
Charcot joint and Argyll Robertson pupils
2
(accommodation but not light response)
31. Lupus
• Tissues and cells are damaged by
deposition of pathogenic antibodies
and immune complexes
β-cell hyperactivity, production of
autoantibodies with specificity for
nuclear antigenic determinants and
abnormalities in T-cell function
occur
32. Meningococcal septicemia
• 30%-50% of those who develop
meningococcal disease have
bacteremia without meningitis
• Prodromal syndrome of tussis,
cephalgia, with sudden spike of
pyrexia with 75% developing
petechia with distal necrosis
sometimes developing
• Waterhouse-Friderichsen syndrome
in fulminant disease (10-20%)
33. Disseminated Fat Necrosis
• When associated with pancreatic
cancer can cause lesions (1) from
release of pancreatic enzymes into
the blood or lymph, causing distal
necrosis
• An acute panniculitis (2), causing
1
tender nodules in subcutaneous fat
and may be suppurative (nodular
fat necrosis)
• As panniculitis may result from a
variety of conditions, Weber-
Christian disease is not a specific
entity
2
34. Polyarteritis
• Inflammation of and
damage to blood vessels,
compromise of vessel
lumen and resulting
ischemia
• May be primary or
manifestation of disease or
secondary to another
disease process
35. Tuberculosis
• Lupus vulgaris is a
granulomatous disease of
the skin usually in long-
standing, untreated disease
elsewhere
• Erythema nodosum may be
present, although more
common in other diseases
