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Journal of Feline Medicine and Surgery (2014) 16, 758–763

CASE REPORT

Feline cutaneous lymphocytosis:
case report and summary of theliterature

Marlene S Pariser
DVM1

Practical relevance: Feline cutaneous lymphocytosis is a rare disease characterized by proliferation of
T and/or B lymphocytes in the dermis. Although some of the clinical and histopathologic findings of thiscondition can overlap with cutaneous lymphoma, it is important to distinguish these entities since theirtreatment and clinical outcomes vary greatly.
Scope: This report presents a summary of the literature on feline cutaneous lymphocytosis and describes
a case of this condition which showed some unique clinical features and was successfully controlled withoral glucocorticoids.

Dunbar W Gram
DVM MRCVS DipACVD2
1
Animal Allergy andDermatology, 1100 Eden
Way N, Chesapeake,
VA 23320, USA
2
University of Florida
College of Veterinary
Medicine, College of
Veterinary Medicine, PO
Box 100126, Gainesville,
FL 32610, USA

Corresponding author:
Marlene S Pariser
Email: mspariser@gmail.com
Date accepted:
1 May 2014

758

Cutaneous lymphocytosis is a disease characterized by a proliferation of T and/or B lymphocytes in the dermis.1–3 This rare condition
has been documented in humans, horses,
dogs and cats.1,4–7 This report describes a caseof feline cutaneous lymphocytosis andreviews the literature on this condition.

Case history
A 13-year-old, 3.4 kg female spayed domestic
shorthair cat presented to the referring veterinarian with purple discoloration and alopeciaof the right forelimb near the first digit. it was
treated with a long-acting injectable glucocorticoid (depo-Medrol; Zoetis, 1.9 mg/kg SC)
and the clinical signs resolved for 1 month
but then recurred. The referring veterinarianadministered another injection of the longacting glucocorticoid, resulting in a 1 month
remission, which again was followed byrecurrence of the signs together with an ulceration and surrounding moderate erythema at
the location of the original lesion. There wasalso a new alopecic area with erythematous topurple discoloration of the skin cranial to themetacarpal pad on the same extremity.
Radiographs of the affected area did not indicate any pathological findings.
The lesions were treated with cefovecin
sodium (Convenia; Zoetis, 7.1 mg/kg SC)
and enrofloxacin (Baytril; Bayer, 5.4 mg/kg
Po q24h) based on bacterial culture andsusceptibility testing, and with short-acting

JFMS CLINICAL PRACTICE(dexamethasone sodium phosphate; Butler
Schein Animal Health, 0.76 mg/kg SC) andlong-acting
injectableglucocorticoids(depo-Medrol; Zoetis, 1.9 mg/kg SC); however, the lesions subsequently worsened.
The ulcerated area expanded, and the erythema cranial to the metacarpal pad on the rightpaw intensified. The ulceration bled whentraumatized by normal activity, such as
grooming, though there was no evidence thatthe lesions were pruritic or painful. The affected leg was bandaged to prevent further
trauma.
Seven months after the initial clinical signs
developed, the patient presented to the dermatology service with severe erythema, anulceration near the first digit and a patchy,
erythematous area of alopecia measuring
approximately 3 x 1 cm cranial to themetacarpal pad. Cytology of the ulcerated
area consisted of intracellular coccoid bacteriawith a mixture of mostly degenerative neutrophils and a few lymphocytes. Beneath the
bandage the cat had also developed a superficial pyoderma on the palmar aspect of theright front paw, which was confirmed bycytology. due to the presence of bacteria,
treatment was initiated with oral clindamycin(Lannett, 22 mg/kg Po q12h), with a plan toperform skin biopsies at the next visit.
The pyoderma on the right front paw was
also treated with chlorhexidine wipes(douxo Chlorhexidine 3% PS Pads; Sogeval
q12–24h).

doi: 10.1177/1098612X14545275© iSFM and AAFP 2014

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Figure 1 A diffuse infiltrateof small, monomorphic
lymphocytes occupies theentire dermis. Hematoxylin
and eosin stain, x 20.
Inset: Arrows indicate
epitheliotropic lymphocytes

At the 2 week re-evaluation the bacterial dermatitis appeared to be responding to treatment
as significantly fewer coccoid bacteria werenoted on cytology. However, inflammatory
cells were still present, and the patient’s lesions
had worsened. The first area of ulceration
remained unchanged, but there was a second
ulceration, approximately 1 x 2 cm, lateral to thefirst digit. Between these ulcerations was a welldefined area of moderate erythema and alopecia. The patchy alopecia and erythema cranial
to the metacarpal pad remained unchanged. A
6 mm punch biopsy of the erythematous area ofalopecia between the ulcerations was performed, but due to the highly vascular nature ofthis lesion only one sample could be obtainedfor histopathology, and for this reason tissue
culture could not be performed.
The histopathologic findings consisted of amonomorphic population of small lymphocytes forming a diffuse infiltrate in the superficial and deep dermis. Small numbers ofsimilar lymphocytes were detected in the epidermis and occasionally within the follicularepithelium (Figure 1). The lymphocytes had
sparse to mildly expanded pale cytoplasm
surrounding ovoid nuclei. Mitotic figures
were not seen. Small numbers of mast cells,
large lymphocytes, plasma cells andmacrophages were present in the infiltrate.
The pattern of dermal infiltration accompanied by minor epitheliotropism, the cellularmorphology and the low mitotic index were
supportive of cutaneous lymphocytosis(Figure 1). immunohistochemistry revealed apredominance of Cd3-positive T cells withsmall randomlyscattered clusters of Cd79areactive B cells (Figures 2 and 3).8 An archived
formalin-fixed, paraffin-embedded skin biopsy was submitted to the Leukocyte Antigen
Biology Laboratory at UC davis for molecularclonality analysis, which revealed T cell
receptor gene rearrangement (TCRg).9 Basedon these findings a diagnosis of feline cutaneous lymphocytosis was made.
The patient was started on oral dexamethasone (decadron; Par Pharmaceutical, 0.15
mg/kg Po q24h for 14 days) and cefovecin
sodium injection (0.4 ml SC once). After 2
weeks of treatment a slight improvement wasnoted; there was one remaining ulcerationadjacent to the first digit and mild erythemacranial to the metacarpal pad. The cat wascontinued on the same dosage of dexamethasone and an additional cefovecin sodium
injection was administered (0.4 ml SC once).
After a further 4 weeks there was significant
improvement in the lesions. The ulceration
had resolved completely and was replaced by
mildly erythematous intact skin and alopecia.
The mild erythema cranial to the metacarpal
pad was reduced in size by about 50%.
Complete blood count (CBC) and chemistry
profile were within normal limits. At thisThe patternof dermal
infiltrationaccompanied
by minorepitheliotropism,
the cellularmorphology andthe low mitotic
index were
supportive of
cutaneous
lymphocytosis.

Figure 2 Virtually all of the lymphocytes express CD3. One such lymphocyte

Figure 3 A few of the lymphocytes were CD79a-positive B cells (arrow).

in the epidermis is indicated by the arrow. Immunohistochemistry CD3, x 20

Immunohistochemistry CD79a, x 40

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Figure 4 Palmar aspect of the right front paw with

Figure 5 Right front paw with partial alopecia andsevere alopecia, erythema and depigmentation of
the paw pads and surrounding skinsevere erythema

point the patient’s dexamethasone wastapered to 0.15 mg/kg Po q48h for 2 weeks,then 0.07 mg/kg Po q48h, and the cefovecin
sodium injections were discontinued.
For the next 6 months the erythema andalopecia continued to improve slightly.
Treatment with dexamethasone (0.07 mg/kg
Po q48h) was maintained. The dexamethasone dose was not reduced further because
the affected areas were not completely controlled, but the disease was considered stable
at this point.
After another 6 month period of stability,
there was slow progression of clinical signs
over 3–4 months. The alopecic, erythematous
skin area cranial to the metacarpal pad began
to increase in size to encompass the wholepalmar aspect of the right paw. There was also
depigmentation and erythema of the paw
pads (Figure 4). The cranial aspect of the rightfront paw had moderate to severe erythemaand patchy alopecia extending from the distal
phalanges to the first digit (Figure 5). A newlesion appeared on the cranial aspect of theright forelimb at the elbow, and developed
into an alopecic, erythematous patch measuring 2 x 3 cm. The patient also started to develop moderate erythema on the cranial aspect of
the carpal region of the left front paw pad(Figure 6). At this point the dexamethasone
dose was increased, initially to 0.15 mg/kg Po
q48h and subsequently to 0.15 mg/kg Po
q24h, after which the lesions stabilized but
did not regress. The skin lesions remained
stable over the following 4 months. Repeat
CBC and chemistry profile were within
normal limits.

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Figure 6 Left front paw with erythema

The typical clinical presentation of feline cutaneous
lymphocytosis is a solitary lesion showing alopecia,
erythema and scaling, with or without crusting– most commonly on the thorax. Most cats do not
become systemically ill.
Discussion and literature review
Cutaneous pseudolymphoma is a broad term
used to describe a clinical or histopathologic
lesion that resembles lymphoma.1 in human
medicine it can be further broken down into
Spiegler-Fendt sarcoid, lymphocytoma cutis,
lymphadenosis benigna cutis and cutaneous
lymphoid hyperplasia.1 The last, cutaneous
lymphoid hyperplasia, is the preferred term as
it most directly describes the pathophysiology.1
Most human cases of cutaneous lymphoid
hyperplasia are idiopathic, but these lesions
have also been linked to bites and stings byarthropods, infections, tattoos, acupuncture,trauma, gold jewelry, vaccinations, andhyposensitization injections or medications.1
in veterinary medicine, cutaneous lymphocytosis has been the preferred terminology,5but it has been suggested that the term cutaneous lymphoid hyperplasia may be moreaccurate.8 As described by Gilbert et al, cutaneous lymphocytosis ‘implies neither a specificdisease, nor a causation, but simply designatesa process of accumulation of lymphocytes inthe skin’.5

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Feline cutaneous lymphocytosis is a rare disease characterized by proliferation of small,
mostly T lymphocytes in the superficial anddeep dermis.4,5 The disease is most often seenin older cats, averaging 12–13 years; there is nobreed predisposition, but there may be a slight
predominance of females.4–6 The duration of
disease at the time of diagnosis varies from
2 weeks to 48 months. The disease isgenerally characterized by acute onset withslow progression.4,5 Although generally considered a benign condition, malignant transformation has been observed (see later).4,5,10 The
etiology is unknown;4–6 however, the presenceof clonal gene rearrangement suggests that thisis a low-grade or indolent lymphoma.4,10
The typical clinical presentation is a solitarylesion showing alopecia, erythema and scaling,with or without crusting, most commonly on
the thorax.4–6 in some cases there are multiple
lesions on various body sites (thorax, leg, pinna,flank, neck, abdomen, paw pad, between thescapulae, elbow, caudal thigh, hip, digit andplanum nasale).4–6 other clinical presentations
include alopecic erythematous plaques, single
or multiple nodular lesions, solitary ulcers, miliary papules, proliferation of the paw pad andulcerations of the planum nasale.4–6 Pruritus
and sometimes excoriation and ulceration canbe seen in about half of cases.4–6 Lesion size isvariable (1.5–12 cm diameter).5
Blood studies are generally unrewarding.5
Most cats are feline leukemia virus and feline
immunodeficiency virus negative.5
Histopathologic findings in an early lesion
consist of a perivascular to diffuse infiltrate ofsmall lymphocytes in the superficial dermis,
but as the disease progresses the infiltrate can
extend into the deep dermis.4–6 The lymphocytes have dark nuclei with compact chromatin and a small to moderate amount ofcytoplasm.4,5 Mitotic figures are absent torare.4,5 The majority of the lymphocytes are
Cd3ε+ T cells which express Cd18, Cd3 andCd5.4,5in approximately half of all cases there aresmall, tightly packed aggregates of smaller B
lymphocytes (Cd79a+, Cd21+) with minimal
cytoplasm.4,5 Some cases show epitheliotropism of lymphocytes into the epidermis orfollicular epithelium.5 Moderate epidermal
hyperplasia, erosion and ulceration may bepresent.5
Treatment results are variable. in one casesurgical excision of a solitary lesion was initially successful, but a new lesion returned
after 18 months, prompting additional
surgery, the outcome of which is unclear.5
Response to systemic or topical glucocorticoid
treatment is also variable: 14/18 cats reportedly showed some response to these inter ventions.5,6 When this approach failed, theMost of thefeatures in thiscase wereconsistent withprevious
cases – thiswas an older
female cat, theetiology was
unknown, andthe processdeveloped
acutely withslow
progression.
Less common
features werethe multiple
lesions on both
front limbs.

addition of chlorambucil or lomustine led toan additional response in 4/5 cats.5,6in general the disease runs an indolent but
benign course with treatment.4,5 Most cats do
not become systemically ill. However, insome cases weight loss and anorexia have progressed to the point of euthanasia.4,5
on necropsy gross lesions were noted in fourcats.5 Cytology or histology of these lesions
showed a monomorphic infiltrate of lymphocytes similar to that seen in the skin.5 it is notknown whether these lesions preceded or followed the development of cutaneous lesions.4,5There is some evidence that feline cutaneous lymphocytosis may undergo malignant
transformation, as is occasionally seen in
analogous human cases.1,2,4,5,11 Notably, somecases have exhibited systemic lymphoid
involvement – such as ascites, enlarged
mesenteric lymph nodes and peripheral
lymphadenopathy, infiltration of liver, pancreas, stomach, kidney and heart by T cell
lymphocytes, and B cell infiltration of thesmall intestine.5
Most of the features of the current case wereconsistent with those of previous cases, as thiswas an older female cat, the etiology of thecondition was unknown, and the processdeveloped acutely with slow progression
and typical histopathologic findings andepitheliotropism.4–6
immunohistochemistry results agreed withthe published data in showing a predominance of Cd3-positive T cells and small
clusters of Cd79a-positive B cells.4,5 Clonality
analysis also showed T cell clonal rearrangement, which has been seen in some cases.4,10
The clonal rearrangement suggests a neoplasic
process; cutaneous lymphocytosis may actually be a form of indolent T cell lymphoma.4,10
A different form of lymphoma, cutaneous T
cell lymphoma, is a common differential for
cutaneous lymphocytosis. However, the treatment, response rate and clinical outcomes differ (Table 1). Both forms show proliferation ofsmall to medium-sized lymphocytes in thedermis, but some features, such as significant
involvement of the epidermis or the follicularepithelium, nuclear atypia and Pautrier’s
microabscesses, are found in cutaneous T cell
lymphoma.12
Exfoliative erythroderma, alopecic patches
or ulcerations, which are clinical presentationsof cutaneous T cell lymphoma, can overlap
with the clinical lesions of cutaneous lymphocytosis; however, the treatment response isvery different.12 There are a number ofchemotherapeutic options for cutaneous T cell
lymphoma, but such therapy is not as effectivein cutaneous lymphocytosis.12,13 in a recent
case report of a feline patient with cutaneous
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Table 1Comparison of cutaneous lymphocytosis and cutaneous T cell lymphoma in feline patients
Cutaneous lymphocytosis

Cutaneous T cell lymphoma

Age of onset

12–13 years

10 years

Sex predilection

Slightly toward female

None

Breed predilection

None

Not reported

Duration of diseaseat time of diagnosis

2 weeks to 48 months

Most cases have chronic skin disease before diagnosis< Solitary lesion showing alopecia, erythema and scaling,with or without crusting< Highly variable

Clinical signs< Solitary or multiple lesions without any predilection< Less common presentations include alopecia and scaling,
for body sites, although the face is commonly affectedwith or without crusting, alopecic erythematous plaques, < Erythematous plaques or patches, scaly alopecic patches,
single or multiple nodular lesions, solitary ulcers, miliary
non-healing ulcers or nodules, crusting miliary
papules, proliferation of the paw pad and ulcerations
multicentric dermatitis, exfoliative erythroderma andof the planum nasale
focal hypopigmentation have been seen. Regional< Pruritus, excoriation and ulceration are present inhalf of cases

lymphadenopathy is common< Variable pruritus

Location of clinicalsigns

Thorax, leg, pinna, flank, neck, abdomen, paw pad,between the scapulae, elbow, caudal thigh, hip, digitand planum nasaleFace, eyelid, mucocutaneous junction, elbow, trunk

Lesion size

1.5–12 cm diameter

Not reported

Disease progression

Acute onset but slow progression

History of chronic skin disease with slow progression

Disease outcome

Disease considered benign

Disease considered malignant

Laboratory results

Unrewarding

Not reported

Histopathologic signs < Lesion consists of a perivascular to diffuse infiltrate ofsmall lymphocytes in the superficial dermis, but as thedisease progresses the infiltrate can extend into thedeep dermis< Lymphocytes have dark nuclei with compact chromatin
and a small to moderate amount of cytoplasm< Mitotic figures are absent to rare and slightepitheliotropism can be present

Immunohistochemistry < Majority of lymphocytes are CD3ε+ T cells which express
CD18, CD3 and CD5< Epitheliotropic lymphoma: diffuse superficial or follicularepitheliotropism of small to medium or medium to large
lymphocytes of the epithelium and adnexal structures.
The lymphocytes have a convoluted nucleus. Pautrier’s
microabscess can be present. Dermal lymphocytic
infiltration has been reported< Spongiosis and keratinocyte apoptosis are noted
as secondary changes< Non-epitheliotropic lymphoma: deep dermal andsubcutaneous non-encapsulated masses of small cell,large cell or immunoblastic lymphocytic infiltrate which
gives it a ‘bottom heavy’ configuration. Adnexal structures
are not affected. Mitotic activity variable
One case of CD8-positive T cell lymphocytes reported< Rarely small tightly packed aggregates of smaller
B lymphocytes (CD79a+, CD21+) with minimal cytoplasm
are present

Treatment

Surgical removal, systemic or topical glucocorticoids,
chlorambucil or lomustine

Glucocorticoids, lomustine, CCNU, surgery, electron beamirradiation, vincristine/cyclophosphamide and intravenous
and local administration of fibronectin

Treatment outcome

Variable, but in most cases lesions continue to progressin an indolent but benign form despite treatment

Variable depending on the agent used, but in most cases
remission can be achieved for up to 15 months

Survival time

Up to 49 months, with median survival time of 11 months

Variable – median survival 10.25 months, but as low as 1–6
months reported

nosed as lymphoma there was no clinicalresponse to the commonly used chemotherapies.13 in cutaneous T cell lymphoma it isreasonable to expect remission or at least
improved quality of life for up to 15 months
with treatment, but cutaneous lymphocytosis
generally shows slow progression of clinicalsigns with stable quality of life despite treatment.4–6 Feline cutaneous T cell lymphoma
and cutaneous lymphocytosis do have a similar median survival time, but patients withcutaneous lymphocytosis have survived for
up to 49 months while cutaneous T cell lym-

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phoma survival, in some studies, has been as
low as 1–6 months.5,12 Thus, although cutaneous lymphocytosis may be an indolent formof T cell lymphoma, it has a very different
disease progression, outcome and response totreatment – as such, it is an important distinction in feline patients.
The current case showed some less commonly noted features, namely multiple
lesions which developed slowly on both front
limbs. Lesions initially had a purplish color,which has not previously been reported, andthe uncommon feature of ulcerations. initially758_763_Case report_Feline cutaneous lymphocytosis.qxp_FAB 31/07/2014 14:38 Page 763

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complete remission was seen with injectableglucocorticoids, but eventually the disorderrecurred. As is true in about half of reported
cases, the lesions in the current case wereasymptomatic and non-pruritic.4–6
in previously reported cases response totreatment was variable.5,6 in the current casedexamethasone therapy resulted in lesion
stabilization which was maintained, albeit
with dose adjustment. Complete remission
with dexamethasone was never achieved.
As of the last clinical encounter, thepatient’s lesions remained stable with theadjusted dosage of dexamethasone, and there
was no evidence of malignant transformation.

Conclusions
The literature on feline cutaneous lymphocytosis is limited, consisting of case reports
and small case series.4–6,13–16 More informationis needed to aid in diagnosis of this rare
condition and to completely understand the
etiology, full range of clinical expression, andtreatment options. it is also important thatclinicians recognize the difference between
cutaneous T cell lymphoma and cutaneous
lymphocytosis as the treatment response,
prognosis and outcomes are very different.

Acknowledgements

3

Cutaneous
lymphocytosis
may be anindolent formof T cell
lymphoma,but has a very
different
diseaseprogression,outcome andresponse totreatment,
which areimportantdistinctions infeline patients.

Thank you to Patrick Hensel and William Brewer
for their editorial service and Tammy Johnson for
her assistance with histopathology.

Funding
The authors received no specific grant from any
funding agency in the public, commercial or notfor-profit sectors for the preparation of this casereport.

Conflict of interest
The authors do not have any potential conflicts ofinterest to declare.

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Gilliam A and Wood G. Cutaneous lymphoid
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Kluger N, Vermeulen C, Moguelet P, Cotten H,
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