Nasal-type extranodal natural killer ⁄ T-cell lymphoma presenting with extensive leg ulcers H. Y. Chia, H. L. Tey, K. B. Tan* and W. S. Chong Department of Dermatology, National Skin Centre, Singapore; and *Department of Pathology, Yong Loo Lin School of Medicine, National University Health System, Singapore doi:10.1111/j.1365-2230.2009.03428.x Summary Primary cutaneous T-cell lymphomas are rare and can be difficult to classify precisely. We present a case of extranodal natural killer (NK) ⁄ T-cell lymphoma in a previously healthy, immunocompetent man who presented with extensive necrotic leg ulcers and disseminated skin nodules. Immunohistochemical studies revealed that the tumour cells were positive for CD3, CD30, granzyme B and T-cell intracellular antigen-1, and negative for CD5 and CD56, with positive staining for Epstein–Barr virus (EBV) RNA on in situ hybridization. A diagnosis of extranodal NK ⁄ T-cell lymphoma was made, based on the presence of cytotoxic granules and positive EBV RNA staining. The patient was treated with a regimen of chemotherapy comprising corticosteroids, intravenous methotrexate, ifosphamide, L-asparginase and etoposide with initial response. Primary cutaneous T-cell lymphomas are rare and can be difficult to classify precisely, depending on their clinical behaviour, location, morphology and immunopheno- type. Treatment and prognosis differs depending on the type. We present a case of extranodal natural killer (NK) ⁄ T-cell lymphoma in a previously healthy, immuno- competent man who presented with extensive necrotic leg ulcers and later developed disseminated skin nodules. Report A 51-year-old Chinese man presented with a gradually enlarging necrotic ulcer over his left ankle. Multiple similar ulcers had developed over his left lower leg subsequently, and become confluent. Five months after the onset of the ulcers, erythematous plaques had started to appear over his trunk and limbs. He had experienced intermittent episodes of fever with a weight loss of 3 kg during this period. On physical examination, multiple confluent necrotic ulcers were found, extensively affecting the patient’s left leg (Fig. 1a). These ulcers had irregular margins, violaceous borders, central eschar, and areas with a sloughy base. There were multiple infiltrated plaques and nodules scattered over the trunk and limbs, many of which had later broken down to forms ulcers with central eschar. The patient had a persistent spiking fever up to 42 °C. The remainder of the examination was unremarkable and there were no palpable cervical, axillary, or inguinal lymph nodes. The differential diagnoses considered were neutro- philic dermatoses (pyoderma gangrenosum and Sweet’s syndrome), infections (Mycobacterium tuberculosis, atyp- ical Mycobacterium and deep mycoses), cutaneous lym- phoma, autoimmune disorders (vasculitis and leprosy in reaction) and febrile ulceronecrotic pityriasis lichenoides et varioliformis acuta. Investigations revealed normal total white cell count (8.6 · 10 9 ⁄ L) and haemoglobin level, (13.0 g ⁄ dL), with an increased platelet count (763 · 10 9 ⁄ L) and reduced creatinine level (58 lmol ⁄ L). Thrombophilic screen for protein C, protein S, antithrombin III, lupus anticoagu- lant and anticardiolipins gave negative results. The patient was also negative for antinuclear, antineutro- philic cytoplasmic and antiextractable nuclear antigen Correspondence: Dr Hui Yi Chia, Department of Dermatology, National Skin Centre, 1 Mandalay Road S308205, Singapore E-mail: hychia@nsc.gov.sg Conflict of interest: none declared. Accepted for publication 12 January 2009 Clinical dermatology • Concise report Clinical and Experimental Dermatology Ó 2009 The Author(s) Journal compilation Ó 2009 British Association of Dermatologists • Clinical and Experimental Dermatology, 34, e693–e695 e693