Anaplastic large cell non Hodgkin's lymphoma presenting as diffuse cutaneous hyperpigmentation

{Figure 3} Computerized tomogram-guided biopsy from the mediastinal lymph node showed a neoplasm with atypical lymphocytes, multinucleated giant cells with wreath-like nuclei, and mixed inflammatory infiltrate composed of eosinophils and neutrophils [Figure 3]b. Immunohistochemistry found the cells to be positive for CD3, CD30 [Figure 4]a, and epithelial membrane antigen (EMA) and negative for CD20, CD15, anaplastic lymphoma kinase [Figure 4]b, and paired box (PAX) 5 [Figure 4]c confirming the diagnosis as anaplastic large cell non-Hodgkins lymphoma- stage 2B as per Ann Arbor staging system (International prognostic index score was 1) with generalized hyperpigmentation and pruritus as a paraneoplastic phenomenon. [2] Presently, 2 months after completion of chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisolone, the patient has attained complete resolution of neoplasm and pruritus, marked improvement in cutaneous hyperpigmentation and has gained weight [Figure 1]b.{Figure 4} Anaplastic large cell lymphoma is categorized into anaplastic lymphoma kinase-positive and negative anaplastic large cell lymphoma and primary cutaneous anaplastic large cell lymphoma. [3] Clinical picture and skin biopsy findings in our case ruled out lichen planus pigmentosus, scleroderma, acanthosis nigricans and direct cutaneous involvement by anaplastic lymphoma kinase-negative anaplastic large cell lymphoma and pointed to diffuse hyperpigmentation and pruritus appearing as paraneoplastic phenomenon.