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December 2007, Vol 64, No. 12 >

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Images in Neurology | December 2007

Acquired Hypopigmentation (Leukoderma) as a Presenting Feature of Metastatic Amelanotic Melanoma With Brain Involvement

Ioannis Karakis, MD; Brian McGeeney, MD; Maria-France Demierre, MD; Jens J. Thiele, MD; Deon Wolpowitz, MD; Jag Bhawan, MD
Arch Neurol. 2007;64(12):1786-1787. doi:10.1001/archneur.64.12.1786.
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A 57-year-old man with no relevant medical history was initially seen with clumsiness and judgment errors while driving for the past 3 weeks. His neurological examination results revealed cognitive impairment and a left homonymous hemianopsia. Skin examination findings were remarkable for multiple oval well-defined depigmented macules on the back of his hands, feet, and neck that were first noticed during the preceding months (Figure 1). On his left shoulder, there was a 1-cm round erythematous nodule (Figure 2).
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Figure 1.

Macroscopic views of leukoderma of the hands (A) and neck (B).

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Figure 2.

Macroscopic view of amelanotic melanoma of the left shoulder. Scale set at centimeters.

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Figure 3.

T-2 weighted image of the brain showing a lesion isointense to the cortex (arrow) consistent with low melanin content.

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Figure 4.

T-1 weighted image of the brain with gadolinium showing enhancement of the lesion (arrow).

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Figure 5.

Low-power (×2) hematoxylin-eosin–stained tissue section from the left shoulder showing a dermal diffuse nodular infiltrate. Left inset, Higher power (×40) view showed nested aggregates of atypical epithelioid cells exhibiting nuclear pleomorphism and hyperchromasia. Right inset, Positive immunohistochemistry with Mart-1/Melan-A (×40), HMB45 (not shown), and S100 (not shown) confirmed the melanocytic nature of this lesion. Although the diagnosis of metastatic melanoma with focal epidermotropism (not shown) was favored, a primary nodular melanoma 7 mm in depth and extending at least to Clark level IV could not be entirely excluded.

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Figure 6.

Mid-power (×10) immunoperoxidase-stained section of skin from the right lower abdomen (control area) (A) and left wrist (leukoderma area) (B) with Mel-5 (tyrosinase-related protein 1). A, Positive staining for melanocytes (red) indicated the normal number and distribution of melanocytes along the basal layer of the epidermis. Inset, Higher power (×40) view showed the Mel-5–positive melanocytes at the dermoepidermal junction. B, Note the loss of basal layer melanocytes. Inset, Higher power (×40) view showed the dermoepidermal junction.

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