Snapshot A 50-year-old man originally from the Carribean islands complains of weakness and chronic constipation. He has an erythematous rash covering > 90% of his body surface area, with well-demarcated papules as well as purpuric lesions. He is also found with hepatosplenomegaly and lymphadenopathy. A peripheral blood smear reveals “flower” cells. Introduction ATLL is an aggressive mature T-cell malignancy a type of cutaneous T-cell lymphoma Pathogenesis human T-cell lymphotrophic virus (HTLV-1) Epidemiology endemic regions Japan Caribbean sub-Saharan Africa Middle East Central and South America Characteristic finding is “flower” cell on peripheral blood smear Presentation Symptoms hypercalcemia constipation altered mental status kidney stone weakness fatigue anorexia Physical exam hepatoseplenomegaly in 50% lymphadenopathy in almost all skin lesions variable morphology plaque, papule, nodulotumoral, erythroderma, and purpuric Evaluation Complete blood count > 5% abnormal lymphocytes Peripheral blood smear with “flower” cells Serology antibodies to HTLV-1 Hypercalcemia Flow cytometry or immunohistochemistry CD4+, CD25+, CD52+, CD7-, and CD8- Imaging for lytic lesions Differential Diagnosis Mycosis fungoides Sézary syndrome Cutaneous metastases of other malignancy Treatment Zidovudine INFα Chemotherapy Prognosis, Prevention, and Complications Prognosis poor median survival time 6 months - 2 years Prevention to prevent mother to infant transmission cessation of breastfeeding in moms with known HTLV-1 avoid sexual contact with infected individuals Complications opportunistic infections lytic bone lesions