Pemphigus foliaceus-like, immunologically negative dermatosis in a patient with T cell chronic lymphocytic leukemia

A 56-year-old black man developed a pemphigus foliaceus-like bullous eruption as the initial presentation of chronic T cell lymphocytic leukemia. Histologic examination disclosed superficial acantholysis consistent with pemphigus foliaceus and an infiltrate of atypical lymphoid cells in the papillary dermis. Repeated direct and indirect immunofluorescence studies yielded negative results. Acantholysis could be reproduced in vitro by incubation of normal human skin with the patient's serum and plasma but not with blister fluid. In the following months, the course of the bullous eruption paralleled that of the leukemia.