Abstract

A 55-year-old woman complained of increased swelling in her left periorbital area and forehead. Her medical history told us that over the past two years, she had repeated occurrences of mild, painless, non-pulsatile scalp swellings that were only over her head and unrelated to any underlying tissue. Over the last three months, the scalp lesions have grown to cover most of the scalp and become undulating, giving the head an uneven appearance. She developed complete left ophthalmoplegia upon evaluation, with no history of any constitutional symptom. A brain scan with contrast-enhanced MRI showed diffuse pachymeningitis and hypo-intense thickening of soft tissues near the left orbital apex and left cavernous sinus. All blood reports pertaining to the differentials and cerebrospinal fluid analysis were within normal ranges. A biopsy confirmed that the lesion in the skull was a diffuse large B-cell lymphoma of the GCB type. Finally diagnosed with NHL, our patient presented with an unusually isolated skin illness that had been indolent for two years, without any constitutional symptoms. The delay in diagnosis could have been avoided if we had set a lower criterion for skin biopsy for recurrent skin lesions at the time of initial presentation. Our case strongly conveys that we should not underestimate any skin lesion, consider all possible secondary differentials during the initial presentation, and act as soon as possible.