Open Access Case Report

DOI: 10.7759/cureus.2466

Mass Compression from Recurrent Lymphoma Mimicking Lower Extremity Cellulitis
David G. Li 1 , Katherine M. Krajewski 2 , Arash Mostaghimi 1

1. Department of Dermatology, Brigham & Women’s Hospital, Harvard Medical School 2. Department of Imaging, Dana-Farber Cancer Institute; Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
 Corresponding author: David G. Li, dgli@bwh.harvard.edu Disclosures can be found in Additional Information at the end of the article

Abstract
Cellulitis is a common skin and soft tissue infection with substantial misdiagnosis rates due to its nonspecific clinical characteristics. In this report, we present a patient with recurrent metastatic diffuse large B-cell lymphoma (DLBCL) masquerading as a unilateral lower extremity cellulitis. A 62-year-old man with a history of DLBCL, in remission for two years, presented with a two-week history of swelling and erythema of the right thigh and leg. Despite treatment with clindamycin and cephalexin, the redness and swelling continued to progress. On presentation to the emergency department, vitals were within normal limits, laboratory workup was significant only for borderline anemia and thrombocytopenia, and bilateral lower extremity ultrasound was negative for a clot. The patient was evaluated by a dermatologist who recommended further imaging workup for proximal vascular compression given the uniformity of inflammation and edema in the absence of fever or systemic symptoms. Imaging revealed retroperitoneal lymphadenopathy, right pelvic side wall and right inguinal lymphadenopathy, an intramuscular lymphomatous involvement of the right iliopsoas muscle, and mass compression of the right external iliac vein. Bone marrow and soft-tissue biopsies confirmed recurrent and metastatic DLBCL. In this patient, the atypical cellulitis-like features are likely due to venous and lymphatic obstruction secondary to mass effect from metastasis. Going forward, clinicians should consider compression-induced edema as a sign of primary or recurrent malignancy in patients with refractory or atypical cellulitis.

Received 03/05/2018 Review began 03/07/2018 Review ended 04/09/2018 Published 04/12/2018
© Copyright 2018 Li et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Categories: Dermatology, Oncology Keywords: cellulitis, pseudocellulitis, lymphoma, compression, diffuse large b-cell lymphoma (dlbcl), cancer, erythema, edema
Introduction
Cellulitis is an infection of the deep dermis and subcutaneous tissue that often presents as expanding erythema, swelling, warmth, and tenderness of the affected site [1]. The lack of a “gold standard” diagnostic modality and nonspecific clinical characteristics results in frequent misdiagnosis of cellulitis mimickers (pseudocellulitis) as cellulitis, leading to inappropriate antibiotic therapy and potential complications [2]. In this report, we present a case of recurrent metastatic diffuse large B-cell lymphoma (DLBCL) mimicking a unilateral lower extremity cellulitis.
Case Presentation

How to cite this article Li D G, Krajewski K M, Mostaghimi A (April 12, 2018) Mass Compression from Recurrent Lymphoma Mimicking Lower Extremity Cellulitis. Cureus 10(4): e2466. DOI 10.7759/cureus.2466

A 62-year-old man with a history of DLBCL previously treated with autologous stem cell transplant and combination chemotherapy with rituximab, in remission for two years, presented with a two-week history of swelling and erythema of the right thigh and leg. The symptoms began acutely as an erythematous patch on his right thigh, at which time he was started on oral clindamycin for presumed cellulitis. Despite a seven-day-course of clindamycin, the patient reported progression of erythema down his leg and was subsequently transitioned to three days of oral cephalexin, also without improvement.
On presentation, the patient had confluent erythema and mild edema from the right upper thigh to the medial calf without tenderness or pruritus (Figures 1-2). His blood pressure was 123/62 mmHg; heart rate 83/minute; temperature 37.0 C (98.6 F); respiratory rate 18; and oxygen saturation 97%. Complete blood count was remarkable only for borderline anemia and thrombocytopenia. The patient’s asymmetry, leukocytosis, tachycardia, age ≥ 70 (ALT-70) lower extremity cellulitis score was three (unilateral disease, no leukocytosis or tachycardia, age < 70), an indeterminate finding that may benefit from further workup or consultation [3]. Ultrasound evaluation of the lower extremities for clot was unremarkable. The patient was evaluated by dermatology during this encounter, who recommended imaging workup for possible proximate vascular compression considering the uniformity of inflammation and edema in absence of fever or systemic symptoms.

FIGURE 1: Compression lymphadenopathy mimicking cellulitis