Ulcerative Necrobiosis Lipoidica in the Setting of Epstein-Barr Virus-Positive Diffuse Large B-Cell Lymphoma and Glucose-6-Phosphate Dehydrogenase Deficiency

Sep 30, 2026

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Necrobiosis lipoidica (NL) is a chronic granulomatous disease, commonly appearing as yellow atrophic plaques and ulcerations on the lower extremities. This case describes an exacerbation in a patient with glucose-6-phosphate dehydrogenase deficiency, where clinical and histopathologic findings supported NL and subsequent evaluation identified oropharyngeal Epstein-Barr virus-positive diffuse large B-cell lymphoma. After lymphoma-directed therapy and management of NL, the patient reported improved pain and ulcerations. The report highlights a potential association and urges clinicians to assess for lymphomatous processes when cutaneous granulomas are recurrent or refractory.

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CategoryHealthcare

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Reading Time13 min

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Abstract

Introduction

Case Presentation

Review began 11/27/2025 Review ended 12/06/2025 Published 12/09/2025 © Copyright 2025 Casey et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98791 Open Access Case Report Ulcerative Necrobiosis Lipoidica in the Setting of Epstein-Barr Virus-Positive Diffuse Large B-Cell Lymphoma and Glucose-6-Phosphate Dehydrogenase Deficiency Mary J. Casey 1, Francesca L. Veon 2 , Anisha Bhanot 2, Brad Gehrs 3, Jeffrey D. McBride 2, 3, 4 1. College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, USA 2. Mark Allen Everett Department of Dermatology, University of Oklahoma Health Campus, Oklahoma City, USA 3. Department of Pathology, University of Oklahoma Health Campus, Oklahoma City, USA 4. Department of Pathology and Laboratory Medicine, Oklahoma City VA Medical Center, Oklahoma City, USA Corresponding author: Mary J. Casey, [mary-casey@ou.edu](mary-casey@ou.edu) Abstract Necrobiosis lipoidica (NL) is a chronic granulomatous disease most commonly manifesting as yellow, atrophic plaques and ulcerations on the lower extremities. We present an exacerbation of NL in a patient with a known history of glucose-6-phosphate dehydrogenase deficiency, who, following a clinical and histopathologic diagnosis of NL, was found to have oropharyngeal Epstein-Barr virus-positive diffuse large B-cell lymphoma. After implementation of therapies for lymphoma, chemotherapeutic complications, and NL, the patient reported improvement in both pain and ulcerations. Though noninfectious granulomatous reactions are common in lymphoproliferative disorders, the skin is rarely involved. This case presentation provides evidence for an association between NL and underlying lymphoma development and encourages clinicians to rule out lymphomatous processes in the setting of reoccurring or recalcitrant noninfectious cutaneous granulomas. Categories: Pathology, Oncology, Dermatology Keywords: diffuse large b-cell lymphoma, epstein barr virus positive, glucose-6-phosphate dehydrogenase deficiency, granulomatous reaction, lymphoma, necrobiosis lipoidica Introduction Necrobiosis lipoidica (NL) is a rare, chronic granulomatous disease commonly presenting as erythematouspapules and nodules that coalesce into telangiectatic, atrophic plaques and ulcerations on the anterior aspect of the lower extremities [1] . Other areas of the body such as the upper extremities, groin, torso, and face can be involved, but are less common [1,2] . The majority of presentations are painless, with pain occurring primarily when ulcerations are present. NL predominantly occurs in women with a reported range of 3: 1-5: 1 female-to-male ratio and typically arises in the third to fourth decades of life [1,3] . Pathological features include a swelling of blood vessel endothelium and granulomatous inflammation that spans the entire depth of the dermis, presenting in a layered, horizontal distribution, which is separated by necrobiotic collagen [4] . This presentation is commonly described as a “cake layer” pattern. The etiology of NL is unclear, with leading theories for pathogenesis including microangiopathy, deposition of immunoglobulins, metabolic influences, and abnormal collagen production as potential causative agents [1,2] . NL has been most notably associated with diabetes mellitus; other proposed associations include autoimmune thyroiditis, rheumatoid arthritis, obesity, hypertension, and hyperlipidemia [3,5] . First-line treatment includes intralesional, topical, and occasionally systemic corticosteroids [5,6] . Recently, phototherapy, biologics, immunomodulators, and JAK inhibitors have been shown to further improve outcomes for patients [5,6] . This case report presents an exacerbation of NL in the rare set

FAQs

What is necrobiosis lipoidica (NL) and how does it usually present?

NL is a chronic granulomatous disease that most commonly forms yellow, atrophic plaques and ulcerations on the lower extremities.

How was the associated lymphoma identified in this case?

After NL was diagnosed clinically and histopathologically, further evaluation found oropharyngeal Epstein-Barr virus-positive diffuse large B-cell lymphoma.

What treatment outcomes were reported after lymphoma and NL therapies?

Following lymphoma-directed therapies and management of complications and NL, the patient reported improvement in both pain and ulcerations.

Sep 30, 2026

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