Borrelia lymphocytoma L98.8

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Bäfverstedt Syndrome; benign lymphoplasia of the skin; Borrelial lymphocytoma; Borrelia lymphocytoma; cutaneous B-cell pseudolymphoma; cutaneous lymphoid hyperplasia; LACB; Lymphadenosis benigna cutis; lymphadenosis cutis benigna; Lymphocytoma; lymphocytoma cutis; Lymphoplasia benigne of the skin; multiple sarcoid; Pseudolymphoma; Sarcoid multiple; Spiegler-Fendt sarcoid

History
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Spiegler, 1894; Burckhardt, 1911; Bäfverstedt, 1943

Definition
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Benign, regressing, frequently (or exclusively?) Borrelia-induced, pseudo-lymphoma-like, nodular proliferation of the lymphoreticular tissue of the skin (pseudo-B-cell lymphoma of the skin) with characteristic clinical picture.

Pathogen
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In cases of Borrelia-induced lymphadenosis cutis benigna B. afzelii and B. garinii are detected. Both Borrelia species are not found in North America. Therefore these cases do not occur genuinely there.

Etiopathogenesis
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Today, the clinical picture of the lymhocytoma is primarily attributed to a Borrelia infection, since it often occurs in "reactive skin areas" (earlobes, nipples, genitals, etc.) in the course of an (already receded) erythema chronicum migrans. Often a tick bite is no longer remembered. In 1/3 of the cases Borrelia infections can be detected reliably. In a larger Italian study, 7 cases (1%) of lymphadenosis cutis benigna occurred in 705 people infected with Borrelia

However, 2/3 of the cases remain etiologically unexplained.

Pharmacological causes (drugs, essential oils, contact allergens, e.g. diphenylcyclopropenone ) are probably rare (causality is difficult to prove).

Etiologically unexplained cases are rather called pseudolymphomas of the skin.

Manifestation
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children and adolescents; young adults, rarely is a later age of manifestation

Localization
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Face, especially earlobes, neck, nipple region, vulva and scrotal skin, armpits, back of the foot.

Clinical features
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Mostly solitary, rarely multilocularly occurring, little sharply defined reddish, asymptomatic (no itching, no pain), also reddish-livid or reddish-brown moderately protuberant, soft-elastic, flatly tapering nodule with smooth, sometimes atrophic surface. Sometimes occurring in the centre of an eythema chronicum migrans (see figure).

Laboratory
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Possibly Borrelia antibodies of the IgG and IgM class, possibly BSG increase, leucocytosis and increase of the serum IgM fraction.

Histology
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Inconspicuous epidermis.

Sharply defined, nodular infiltrates of (mature) lymphocytes, plasma cells, germinal cells, macrophages and various admixtures of eosinophilic leukocytes that penetrate the entire dermis. Formation of reactive germinal centres (colourful picture with centrocytes and -blasts, immunoblasts, starry sky cells) is possible. An infiltrate-free subepidermal zone (border zone) is characteristic. Expression of B-cell markers (CD20, CD79a). No monoclonal rearrangement of the genes for the heavy chain of immunoglobulins.

In principle, it is mature lymphatic tissue, the formation of an ectopic "lymph node" of the skin.

Differential diagnosis
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Clinical:

  • Lymphoma, cutaneous: Clinically and histologically most important DD; can only be excluded with certainty in the summary of all examination results.
  • Cutaneous mastocytoma: Either already existing since birth or occurring in the first months of life (exclusion due to age of manifestation). After rubbing the foci urticarial or bullous reaction ( Darian sign).
  • Lupus erythematodes tumidus: Occurs in light-exposed areas; mostly disseminated plaques; pronounced photosensitivity.
  • Sarcoidosis: important as DD is the large-nodular form with brown- or blue-red, coarse, plum-sized nodules and plaques, especially on the nose, cheeks, earlobes. Sarcoidosis often occurs in scarred areas! Diascopic lupoid infiltrate. Histologically safe to differentiate!
  • Tuberculosis cutis luposa (very rare): Mostly acral localized (e.g. on the earlobes), brown flat plaques with atrophic epidermis (wrinkled surface); diascopic lupoid infiltrate. Histologically safe to differentiate!
  • Perichondritis of the auricle: painfully fluctuating swelling, reddened skin, hot, protruding auricle, recess of the earlobe.
  • Eosinophilic granuloma (rare): Roundish to oval, 0.5-2.0 cm in size, usually solitary, slightly raised, firm, asymptomatic, brown-red, scale-free plaques with "orange peel-like" surface aspect. This is missing in lymphadenosis cutis benigna.
  • Merkel cell carcinoma: Occurs in the age group 60 - 70 LJ. Fast growing node; mostly solitary. The surface of the nodule is smooth, rarely crusty or ulcerated. In the depth there is often an iceberg-shaped widening of the nodule.
  • Skin metastases (rare): Nodular metastases are of differential diagnostic importance; mostly fast-growing rough (!) smooth, red nodules. Often iceberg phenomenon.
  • Keloid: Trauma history, very rough consistency.

Histological:

  • Lymphoma, cutaneous germinal center lymphoma: Nodular, mostly irregular infiltrates with indicated germinal center structures; infiltrates of medium-sized centrocytes with mostly clearly notched nuclei, as well as interspersed larger cells with large, round nuclei with one or more prominent nucleoli (characteristics of centroblasts). With the progression of the tumor, follicular structures are less frequently expressed, the number of reactive T cells is relatively reduced. Monomorphic populations of large centroblasts and centrocytes predominate. Monoclonal expression of immunoglobulin light chains.
  • Cutaneous lymphomas of other classification (e.g. lymphoma, cutaneous B-cell lymphoma, marginal zone lymphoma).
  • Lupus erythematodes tumidus: Perivascular or periadnexial, predominantly monomorphic T-cell infiltrates, wherein small round lymphocytes with homogeneous chromatin-tight nuclei predominate. Few plasma cells. Germinal centres may occur, but are rather rare. Focal mucin deposits.

Therapy
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  • Antibiotics: In adults and adolescents > 50kg/KG Doxycycline 2 times/day 100 mg p.o. for 2-3 weeks
  • Alternatively Amoxicillin (e.g. Amoxihexal) 3 times/day 500 mg p.o., Penicillin V (e.g. Megacillin oral Filmtbl.) 3 times/day 1 million IU p.o.
  • Alternative: Erythromycin (e.g. Erythrocin Film) 3 times/day 500 mg p.o.
  • Alternative: Ceftriaxone 1 time / day 2 g i.v. over 2-3 weeks.
  • For children and pregnant women Ampicillin/Amoxicillin, alternatively Erythromycin.
  • In case of therapy failure:
    • Multiple injections with a triamcinolone solution.
    • Individual treatment with photodynamic therapy (PDT): 2-4 sessions at 14-day intervals.
  • Alternatively..:
    • Excision under local anesthesia in case of not too large nodules.

Progression/forecast
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Benign. If left untreated, the lumps remain for months or years. Spontain evolution is common. Increasing magnification is also possible.

Literature
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  1. Adachi T et al (2014) Hapten-induced lymphadenosis benigna cutis secondary to squaric acid dibutylester sensitization for alopecia areata. J Dermatol 41:182-183
  2. Arai E et al (2005) A review of 55 cases of cutaneous lymphoid hyperplasia: reassessment of the histopathologic findings leading to reclassification of 4 lesions as cutaneous marginal zone lymphoma and 19 as pseudolymphomatous folliculitis. Hum Pathol 36: 505-511
  3. Bäfverstedt B (1943) About lymphadenosis benigna cutis. A clinical and pathologically anatomical study. Acta Derm Venereol 23: 1-202
  4. Büchner SA et al (1988) Infiltrative lymphadenosis benigna cutis as borreliosis of the skin. dermatologist 39: 77-81
  5. Burckhardt JL (1911) On the question of the formation of follicles and germinal centres in the skin. Frankfurt Journal of Pathology 6: 352-359
  6. Cerroni L et al (2002) Specific cutaneous infiltrates of B-cell chronic lymphocytic leukemia (B-CLL) at sites typical for Borrelia burgdorferi infection. J Cutan pathogen 29: 142-147
  7. Herder E et al (2010) Successful therapy of a pseudolymphoma with photodynamic therapy. Report of a case. JDDG 8: 952
  8. Krause W (2011) Diseases of the male nipple and areola. J Dtsch Dermatol Ges. 2011 9:1004-1009
  9. Neubert U (1987) Progress in the diagnosis of erythema migrans, lymphadenosis cutis benigna and acrodermatitis chronica atrophicans. Dermatologist 38: S34-S42
  10. Stinco G et al(2014) Clinical features of 705 Borrelia burgdorferi seropositive patients in an endemic area of northern Italy. ScientificWorldJournal doi:10.1155/2014/414505
  11. Weber K et al (1985) The lymphocytoma- a Lyme disease? Z Hautkr 60: 1585-1598
  12. Yoshida Yet al (2003) Lymphadenosis benigna cutis induced by iatrogenic contact dermatitis from dinitrochlorobenzene. Contact dermatitis 49:165-166

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Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020