Atypical shock and skin lesions revealing lymphoma.

a 56-year-old woman was hospitalized because of febrile dyspnoea. She was not taking any regular medication. a full infectious, immunological and radiological work-up was inconclusive. Despite empirical antibiotic treatment targeted against intracellular bacteria (levofloxacin), haemophagocytic syndrome developed and haemodynamic instability prompted a transfer to the intensive care unit (ICU). Echocardiography revealed an altered cardiac output. respiratory assistance and haemodynamic support with vasoactive amines were required after fluid challenge and transfusion of packed red blood cells. a broad-spectrum antibiotic was administered. Multiple bacteriological samples, along with a renewed immunological work-up, were inconclusive. a computed tomography (CT) scan was normal. However, the patient presented skin lesions on the breasts (Fig. 1a). These were violaceous, macular, slightly infiltrated plaques. a skin biopsy showed a perivascular lymphocytic infiltrate in the dermis and hypodermis (Fig. 1b). Immunohistology revealed CD20+ (Fig. 1c), CD3–, CD5– and CD10–. the diagnosis was an intravascular lymphoma. the patient died 4 days later with multiple organ failure before any chemotherapy could be initiated. Case 2.