LAUSR

To the Editor, A 66yearold woman presented with two erythematous plaques on the malar region bilaterally for 2 years. Her medical history was unremarkable and she was taking no medication. Skin lesions had been previously diagnosed as rosacea and unsuccessfully treated with topical metronidazole and ivermectin and systemic tetracycline. Physical examination revealed two erythematous nodules with irregular surface, elastic consistency and poorly defined margins on the malar region bilaterally (Figure 1). The presence of laterocervical and right inguinal lymphadenopathy induced us to perform a highfrequency ultrasound with Hitachi Arietta V70 equipped with multifrequency probes. At the dermalepidermal layer, hypoechoic areas of irregular shape were observed. These lacunae presented intralesional vascularisation and elastosonography showed greater hardness of these areas compared with perilesional healthy skin (Figure 2). Peripheral blood evaluation showed no abnormalities, except for mild anaemia. Normal erythrocyte sedimentation rate, Creactive protein and antinuclear antibodies were observed. We performed a skin biopsy that revealed diffuse nodular interstitial infiltrates of mature lymphocytes in the dermis and subcutaneous tissue, involving also adnexa and vessels. The dermal infiltrate was separated from the overlying epidermis by a distinct grenz zone, with absence of epidermotropism (Figure 3). Lymphoid cells were positive for CD20 and CD79a, but negative for CD5, CD23 and cyclin D. Proliferation index was low (5% Ki67 + ). A molecular analysis made, using polymerase chain reaction (PCR) and a standardized BIOMED2 Gene Scan protocol revealed a clonal immunoglobulin heavy chain rearrangement, identifying a clonal Bcell process. Bone marrow biopsy demonstrated diffuse aggregates of welldifferentiated B cells characterized by the same immunophenotype seen in the skin. In situ hybridization analysis of peripheral blood lymphocytes showed no abnormalities suggestive of chronic lymphocytic leukaemia (CLL). A cutaneous localization of small lymphocytic lymphoma (SLL) was diagnosed.