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Editor,—Lymphocytoma cutis is a benign lymphoid hyperplasia which typically occurs over the head and neck. We report a case of lymphocytoma cutis with conjunctival lesions; only one other case with lesions affecting the conjunctiva has previously been reported.
A 30 year old woman presented with a 10 year history of multiple erythematous papules over her nose, cheeks, and forehead. The papules were more numerous in the summer and the use of sun screens reduced the number of new lesions. Eight years earlier she had developed discrete pink conjunctival lesions. There was no previous history of trauma to the eyes. The lesions were asymptomatic and did not affect her vision. They were surgically excised for cosmetic reasons but reappeared within 2 months.
Examination revealed multiple 1–2 mm erythematous papules over her nose and cheeks. Three flesh coloured lesions were present on the right conjunctiva in the interpalpebral fissure, two medially and one laterally (Fig 1), and one on the left interpalpebral fissure. There was no lymphadenopathy or hepatosplenomegaly and a full blood count, biochemistry profile, and immunoglobulin profile were normal.Borrelia burgdorferi antibodies were not detected.
The histology of a papule from both the nose and conjunctiva was similar showing a discrete lymphoid aggregate with germinal centre formation, prominent tingible body macrophages, and a surrounding mantle zone. Immunohistochemical studies of these lesions demonstrated CD20, CD79a, and CD21 positivity; CD23 and CD10 positivity within the germinal centres; and CD5, bcl-2, and cyclin D1 negativity. There was no evidence of light chain restriction and immunoglobulin gene rearrangement studies were polyclonal on both cutaneous and conjunctival lesions using polymerase chain reaction (PCR) based techniques.
These histological, immunotypical, and genotypic studies are fully consistent with a diagnosis of lymphocytoma cutis.
The number of cutaneous lesions and prominence of conjunctival lesions increases during the summer and there has been some benefit in reducing the number of new cutaneous lesions with the use of sun screens.
Lymphocytoma cutis is a reactive lymphoid hyperplasia. Lesions may be papular or nodular, solitary or multiple. Solitary nodular lesions may resemble cutaneous B cell lymphoma both clinically and histologically but behave in a benign manner.1 The condition most commonly affects the head and neck and, as in our case, may be exacerbated by sun exposure.2 3 Other environmental factors have been implemented in the aetiology of lymphocytoma cutis including Borrelia burgdorferiinfection,4 trauma,5 and certain drugs6; however, most cases of lymphocytoma cutis are of unknown aetiology.
Mucosal membrane involvement with lymphocytoma cutis is extremely rare with only one previously reported case of lymphocytoma cutis affecting the conjunctiva in the German archives in 1935,7 although lesions affecting the oral mucosa have been more frequently described.8 However, the conjunctiva is a recognised site for primary B cell lymphomas, particularly MALT lymphomas. In our case the histology of both cutaneous and conjunctival lesions showed reactive lymphoid follicles with good preservation of the normal architecture, tingible body macrophages, and lack of bcl-2 positivity. In addition, analysis of the immunoglobulin heavy chain genes showed no evidence of a B cell clone, thus helping to exclude the diagnosis of a primary B cell lymphoma.
A foreign body reaction within the eye may also result in similar lesions both clinically and histologically to those of lymphocytoma cutis. However, there was no preceding trauma to the eyes and the fact the lesions are multiple, affect both eyes, and recurred after surgical excision makes the diagnosis of lymphocytoma cutis of the conjunctiva more likely than a foreign body reaction.
Cases of lymphocytoma cutis with conjunctival lesions are extremely rare. In our patient the conjunctival lesions have persisted for a period of 8 years.