LEUKEMIA CUTIS; PSEUDOLEUKEMIA CUTIS³

In some cases of leukemia the skin either directly or indirectly
shares in the malady. The lesions presented, consisting variously in

¹ As to x-ray treatment: Jamieson, Brit. Jour. Derm., 1903, p. 1 (case illustration;
disease disappeared from all parts treated); Jamieson and Hute, ibid., 1904, p. 125 (in
prefungoid stage; no traces remained); Stainer, ibid., 1903, p. 212 (apparently cured);
Marsh, Amer. Jour. Med. Sci., 1903, vol. cxxvi, p. 314-(apparently cured); Ormsby,
Medicine, 1903, vol. ix, p. 904, and Hyde and Montgomery, “Diseases of the Skin,”
seventh ed., p. 779 (prefungoid stage; plaques would disappear under treatment);
Lustgarten, Jour. Cutan. Dis., 1904, p. 185 (case demonstration; patches had almost
entirely disappeared, with the exception of a few unrayed spots, for which patient was
still under treatment; “a single twenty-minute exposure will produce a dermatitis on
any part of the body followed by a complete disappearance of the lesion”; Lustgarten
believes a dermatitis should be provoked by the rays); Elliot, ibid., p. 187 (discussion;
complete disappearance of all lesions); Carrier, Jour. Cutan. Dis., 1904, p. 73 (case
illustration; lesions have entirely disappeared); Bulkley, ibid, (case demonstration;
steady improvement); Dubois-Havenith, Presse med. beige, 1904, vol. lvi, pp. 139 and
423 (symptomatically cured); Belot and Bissérié, Arch. d‘electric med., 1904, vol. xiii,
p. 855, and translation in Arch Roentg. Ray, 1904-5, p. 139, and Belot, Annales, 1904,
p. 588 (eruption practically disappeared under treatment); Markley, Jour. Cutan. Dis.,
1905, p. 440 (disappeared); Jackson, ibid., 1906, p. 193 (apparent recovery for more
than a year—recurrence and death); Lawrence, “x-Ray Bath,” Jour. Cutan. Dis.,
1908, p. 247; Burnside Foster, ibid., 1909, p. 75 (case improving).

² C. J. White, ibid., p. 195, has recorded an instance of fatal toxemia apparently
resulting from the rapid disappearance of the lesions under x-ray treatment; also refers
(with résumé and bibliography) to other reported instances of toxemia following the
treatment of other neoplastic growths—see also Pancoast’s paper, Univ. Penna. Med.
Bull., Jan., 1907.

³ The following papers will be found to cover pretty fully, by review and bibliog­
raphy, the literature of the leukemias: Pincus, Archiv, 1899, vol. 1, pp. 37 and 177;
Nékám, Ueber die leukœmischen Erkrankungen der Haul, 1899, Vose, Hamburg and
Leipsiz; Nicolau, Annales, Aug.-Sept., 1904, p. 753, and also in Unna’s “Histopath-
ology”; Brunsgaard, Hautkrankheiten bei der myeloiden Leukæmia und der malignent
Granulomatose, Arch., March, 1911, cvi (with case report of a fatal leukemia, and a
case of lymph-gland tumors with a blood picture of polynuclear leukocytosis; in both
cases metastatic skin tumors in the form of cutaneous and subcutaneous papules
and nodules; gives a good critical review based largely on the histopathology of the
various skin lesions associated with the leukemias and the malignant granulomata;
Dubreuilh, “Prurigolymphadénique," Annales, 1905, H. 8-9 (concerning especially cases

912

NEW GROWTHS

the cases reported, or in some instances as a medley in the same case,
of true leukemic tumors (Biesiadecki, Hochsinger and Schiff, and others),
dry, and, less frequently, moist, eczema-like areas, often of more or less
general distribution, eczematous or lichenoid papules, infiltrated, thick­
ened, reddish, sometimes pale, areas of skin, with occasionally the lines
and folds accentuated (when, on the face presenting an appearance of
leontiasis); and in some instances the development of diffuse lymphatic
thickening and hypertrophy, with the formation in the lower part of
the corium, or subcutaneously, of discrete, crowded, or chain-like pea
to cherry-sized or larger, doughy or hard, somewhat flattened nodules.
There is usually intense itching, and sometimes a hypersensitive skin,
tender upon touch or pressure, or at times spontaneously painful. The
eczematous element is variable, being more or less intense at different
times or periods, but the tumor-like growths and infiltration are usually
persistent and progressive; exceptionally the eczematoid, thickened
or lymphatic infiltrations give place to atrophic changes. The face, head,
arms, and genital and anal regions are frequently favorite situations for
the more extreme developments; the face and head in those of limited
development. In some of the cases—those in which there is a medley
of tumor formations, eczematoid eruptions, and thickened, infiltrated
plaques—the resemblance, as to external appearances, to granuloma
fungoides is quite striking,¹ but there is rarely any decided tendency to
ulceration, and practically none to the formation of the peculiar fungoid
growths and ulcers of granuloma fungoides. Exceptionally, the mani­
festation may be suggestive of a multiple pigmented sarcoma.² Cases
of the other extreme—in which the visible tumor formation is practically
wanting, and only the smaller subcutaneous nodules, together with a
dry, eczematoid, somewhat shriveled-looking, reddened, slightly scaly
skin, are present—may show some resemblance to pityriasis rubra of
Hebra. Exceptionally an intense pruritus is the sole associated skin
symptom.

Not uncommonly the eczema or eczema-like eruption is the first
symptom to which the patient’s attention is called, and such a con­
dition is usually persistent, with a disposition to infiltrated plaques,
and most intractable to treatment. The itching also seems more or
less uncontrollable. In other instances the eczema-like symptoms are
lacking, the manifestations consisting of from several to large numbers
of variously sized, slightly to prominently projecting, soft, doughy,
firm, sometimes roughly lobulated tumors, over which the skin may or

characterized by pruritus and pruriginous papules, etc, 2 cases of his own; refer­
ences); Hazen, “Skin Changes in the Leukæmias and Allied Conditions, “Jour. Cutan.
Dis., 1911, p. 521 (based upon 2 cases under his own observation (1 case, notes given
by Dr. Strobel), a review of recorded cases, omitting doubtful cases, with brief case
notes and bibliography of the leukemias and allied conditions—an exhaustive and
helpful paper to those interested).

¹ Pelagatti, “Mycosis fungoides und Leukämie,” Monatshefte, 1904, vol. xxxix, pp.
369 and 433 (with histologic cuts), believes granuloma fungoides a leukemia primarily,
with skin manifestations secondarily.

² Rolleston and W. Fox, “A Case of Atypical Myeloid Leukemia with Nodular
Infiltration of the Skin,” Brit. Jour. Derm., 1909, p. 377 (case illustrations—4 histoiogic
cuts, and references).

LEUKEMIA CUTIS; PSEUDOLEUKEMIA CUTIS            913

may not be movable, and which may be of a normal, pale red, yellowish,
or brownish-red color. In these cases the general symptoms of leukemia
may have long preceded these cutanenous manifestations. Later the
leukemia becomes more profound, and there may also be the de­
velopment of lymphatic abscesses, with sometimes a tendency to a
breaking down of the larger growths, exceptionally into gangrenous
ulcers; increasing weakness and prostration of the patient, and finally
death.

The histologic characters of the growths have been studied by various
observers (Biesiadecki, Hochsinger and Schiff, Kreibich, Pinkus, Nékám,
Nicolau, and others). There is found a cellular infiltration in the corium
and subcutaneous tissue consisting largely, as is generally conceded, of
crowded and heaped-up lymphocytes; although some observers believe
the masses are derived from the connective-tissue cells in situ, and others
that they arise from the exudation of leukocytes from the blood-current.

Pseudoleukemia Cutis.—Pseudoleukemia, known commonly as
Hodgkin’s disease, like leukemia, sometimes presents cutaneous mani­
festations (lymphadenoma cutis) closely or practically similar to those
observed in the latter disease, and already described. Bullous lesions
are a rather unusual occurrence.¹ It is believed by some observers² that
a pseudoleukemia sometimes develops into a true leukemia.

Diagnosis.—The recognition of the eruptions of the leukemias
depends largely upon the recognition of the underlying disease. In­
tractable eczematous or eczematoid eruption, especially if at all exten­
sive, with a disposition in places to considerable infiltration, rebellious to
treatment, and with a troublesome, persistent, or paroxysmal itching
difficult to relieve, should always suggest the possibility of granuloma
fungoides, a leukemia cutis, or a pseudoleukemia cutis. Suspicion thus
aroused becomes more probable or almost certain if there is any associated
tumor formation; and as to leukemia and pseudoleukemia, a careful
general examination, as to blood, glands, and internal organs, will usually
determine the matter. That there is often a strikingly puzzling likeness
in the clinical cutaneous ensemble of these three maladies is to be ad­
mitted, so much so as to suggest a possible kinship.³

Treatment.—Hopeless as to final outcome as it usually is, a
proper general plan of treatment is to be instituted. Billings⁴ has ob­
served favorable influence from benzol, but says its use requires caution.
As to the cutaneous symptoms, exceptionally amelioration and in one
or two instances complete relief followed the administration of arsenic,
preferably by hypodermic injection. The x-ray, more especially in

¹ Bloch reports, Archiv (“Erythema toxicum bullosum und Hodgkinische Krank-
heit”), 1907, vol. lxxxvii, p. 287, a case of associated bullous erythema and Hodgkin’s
disease.

²Linser, “Beiträge zur Frage das Häutveranderungen bei Pseudoleukämie,”
Archiv, May, 1906, vol. lxxx; Radaeli, “Mykosis fungoides oder Pseudoleukämie cu-
tanea,” ibid., July, 1906, vol. lxxx.

³1 have met with 3 such puzzling cases in recent years in which the differentiation
symptoms were so ill-defined that a positive diagnosis without qualification could
scarcely be made; all ended fatally. See also foot­note of Pardee and Zeit case, under
Granuloma fungoides.

⁴ Billings, “Benzol in the Treatment of Leukemia,” Jour. Amer. Med. Assoc, Feb.
15, 1913, p. 496 (with pertinent literature references).
58

914

NEW GROWTHS

pseudoleukemia, has given encouraging results.¹ The external manage­
ment of the eruption and tumors is essentially that advised in granuloma
fungoides.

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