patient was treated with prednisone (1 mg/kg/day). Myalgias, impaired renal function, and leucopenia developed. Even though treatment was discontinued 13 days later, skin lesions progressively improved. Two months later the patient died due to progression of the lymphoproliferative process. SS is a primary cutaneous T-cell lymphoma associated with dysregulation of both cellular and humoral immunity. 1 Staphylococcus aureus has been identified as the most common pathogenic organism in cutaneous infections and bacteremias in patients with SS. Disseminated herpes infections are also frequently found with progressive cell-mediated immunity decline. 1 Leishmaniasis due to L. infantum is endemic in Spain, both in immunocompetent and in immunosuppressed patients, and is transmitted by mosquitoes. 2 Disseminated cutaneous leishmaniasis is rarely seen in SS. To our knowledge, there is only one report of cutaneous leishmaniasis in a patient with SS. 3 Cutaneous leishmaniasis caused by dermotropic species may disseminate in immunosuppressed patients and present different clinical characteristics. Poor response to treatment is common and relapses are frequent, 4 depending on the Leishmania strain. 5 Differential diagnosis of disseminated cutaneous eruptions in immunocompromised patients must include other infectious diseases such as leish- maniasis, histoplasmosis, sporotrichosis, and para- coccidioidomycosis. Histopathologic examination is necessary for the diagnosis of cutaneous leishman- iasis, although the parasites may not be found. If clinical suspicion is high, polymerase chain reaction may be useful. 5 Priscila Giavedoni, MD, a Ignasi Pau-Charles, MD, a Jos e M. Mascar o, Jr, MD, a Merc e Alsina-Gibert, MD, a Adriana Garc  ıa-Herrera, MD, b and Teresa Estrach, MD a Departments of Dermatology a and Pathology, b Hospital Cl  ınic, IDIBAPS, Universitat de Barcelona, Spain Funding sources: None. Conflicts of interest: None declared. Correspondence to: Teresa Estrach, MD, Department of Dermatology, Hospital Cl  ınic, UB, C/ Villarroel 170, 08036 Barcelona, Spain E-mail: testrach@clinic.ub.es REFERENCES 1. Olsen EA, Rook AH, Zic J, Kim Y, Porcu P, Querfeld C, et al. S ezary syndrome: immunopathogenesis, literature review of therapeutic options, and recommendations for therapy by the United States Cutaneous Lymphoma Consortium (USCLC). J Am Acad Dermatol 2011;64:352-404. 2. Cortes S, Chicharro C, Cruz I, Cristov~ ao JM, Ca~ navate C, Campino L. Genetic diversity of human zoonotic leishmaniasis in Iberian peninsula. Zoonoses Public Health 2011;58:234-7. 3. Mah e A, Gessain A, Huerre M, Pratlong F, Dedet JP. Erythrodermic diffuse cutaneous leishmaniasis with S ezary syndrome. Lancet 1996;348:405-6. 4. Van Griensven J, Carrillo E, L opez-V elez R, Lynen L, Moreno J. Leishmaniasis in immunosuppressed individuals. Clin Micro- biol Infect 2014;20:286-99. 5. Masmoudi A, Hariz W, Marrekchi S, Amouri M, Turki H. Old World cutaneous leishmaniasis: diagnosis and treatment. J Dermatol Case Rep 2013;7:31-41. http://dx.doi.org/10.1016/j.jaad.2014.07.010 Toxic epidermal necrolysis in the absence of circulating T cells: A possible role for resident memory T cells To the Editor: Toxic epidermal necrolysis (TEN) is a life-threatening mucocutaneous disease with high mortality, mainly induced by drugs. Although the pathogenesis of TEN remains elusive, reports have suggested the importance of T lymphocytes. 1,2 Here, we report a case of TEN that occurred in the absence of circulating leukocytes but in the presence of resident memory T cells (T RM ), suggesting key role(s) for T RM in the pathogenesis of TEN. Fig 1. Toxic epidermal necrolysis. A, Clinical presentation on day 30 after initial chemotherapy. Skin lesions on the back showed exudative erythema with positive Nikolsky sign. B, Histopathologic findings of skin biopsy specimen taken from area of erythema on the left arm. Hematoxylin- eosin staining showed interface dermatitis and exocytosis of mononuclear cells with individual cell necrosis of keratinocytes. Scale bar: 300 m. JAM ACAD DERMATOL NOVEMBER 2014 e214 Letters