Extensive Follicular Crusting with Verrucous Epidermal Hyperplasia and Possible Hemophagocytic Lymphohistiocytosis

Abstract

A 30-year-old woman, with a medical history including marginal zone lymphoma, systemic lupus erythematosus (SLE), acute pancreatitis, and deep vein thrombosis, presented with extensive facial crusting after chemotherapy and prednisone treatment. Diagnosed with crusted folliculitis, verrucous epidermal hyperplasia, and suspected hemophagocytic lymphohistiocytosis (HLH), this case is unique due to the presence of S. lugdunensis and the complexity of concurrent immunomodulatory conditions and treatments. HLH, a systemic inflammatory disorder, disrupts normal physiological processes, predominantly occurring in childhood but also associated with malignancies and infections in adults.

The patient's presentation involved persistent crusted folliculitis related to S. lugdunensis and a yeast infection. Despite challenges in diagnosis, including concurrent conditions like cytomegalovirus, inflammatory reactions, SLE, and recent malignancy, a bone marrow biopsy confirmed HLH. Elevated ferritin levels prompted consideration of HLH within the broader context of SLE and lymphoma. Treatment with high-dose steroids resulted in improvement.

This case highlights the intricacies of diagnosing complex medical conditions, especially when complicated by the presence of specific pathogens like S. lugdunensis. The identification of this bacterium adds an extra layer of complexity, emphasizing the need for a comprehensive approach to address diverse medical challenges. In immunocompromised patients, a meticulous evaluation is imperative upon HLH diagnosis. The discernment of elevated ferritin levels, coupled with vigilant symptom monitoring, facilitates the differentiation of HLH from other inflammatory