Rapidly progressing necrotic ulcerations and sinuses in specific cutaneous Hodgkin's disease

Rapidly progressing necrotic ulcerations and sinuses in specific cutaneous Hodgkin's disease Sir, A 25-year-old gentleman presented with a progressively enlarging swelling over the right side of the neck for seven months. He also had a large fungating ulcer over the right supraclavicular region with extensive edema of the chest wall and right upper limb for three months. He complained of high spiking fever, cough and significant weight loss. Examination revealed a large, soft-to-firm, non-tender, swelling encompassing the neck, right shoulder, arm and upper chest, with visible dilated veins. There were large ulcers with everted margins and a necrotic floor over the supraclavicular region and multiple smaller ulcers over the chest wall [Figure 1]. He had hard and matted cervical lymph nodes. The clinical differential diagnoses of nocardiosis, cervicothoracic actinomycosis, mycobacterial or atypical mycobacterial infection, and lymphoma were considered. The histopathology of the skin and lymph nodes were consistent with a diagnosis of classical Hodgkin's lymphoma, nodular sclerosis type. The skin biopsy revealed dense infiltrates of lymphocytes, plasma cells, histiocytes, neutrophils, eosinophils, and a few scattered medium‑sized cells with vesicular nuclei, visible nucleoli, and moderate amounts of cytoplasm [Figure 2]. On immunohistochemistry, the medium‑sized cells stained strongly for CD30 [Figure 3] and weakly for Pax-5. A submental lymph node biopsy showed many mononucleate cells and occasional binucleate (Reed– Sternberg) cells with prominent nucleoli [Figure 4]; the mononuclear and lacunar cells were positive for CD15 and CD30. Pus culture grew Pseudomonas aeruginosa resistant to all drugs other than aztreonam. A computed tomography scan of the chest revealed suppurative cervical and axillary lymphadenitis along with enlarged paratracheal, subcarinal, and anterior mediastinal lymph nodes. The patient was administered 12 cycles of chemotherapy with adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD) regimen as suggested by the hematologists, with which the ulcers healed [Figure 5], but the disease relapsed 6 months later. Radical dissection of cervical lymph nodes was not done. The patient refused further palliative chemotherapy or radiotherapy and succumbed to the disease six months later. Hodgkin's lymphoma was described by Sir Thomas Hodgkin in 1932. It commonly presents as painless lymphadenopathy, mostly involving lymph nodes above the diaphragm. Cutaneous involvement can be classified as nonspecific skin involvement, specific cutaneous Hodgkin's disease, and primary cutaneous Hodgkin's disease. Primary cutaneous Hodgkin's disease includes histologically proven skin involvement without disease in any other site. In our patient, the rapid progression, the massive swelling with the presence of dilated …