HSHS St. Mary's Hospital Medical Center GREEN BAY, WI
Kwabena O. Adu-Gyamfi, MD1, Sandeep Patri, MD2, Michael Maitar, MD3, Richmond Gyamfi, MD1; 1HSHS St. Mary's Hospital Medical Center, Green Bay, WI; 2HSHS St. Vincent Hospital, Green Bay, WI; 3Southern Illinois University School of Medicine, Springfield, IL
Introduction: Cutaneous leukocytoclastic vasculitis (CLCV) is a disorder of perivascular leukocyte invasion and inflammatory damage to small cutaneous vessels. It typically manifests as palpable purpura starting in the extremities. It may idiopathic, autoimmune, or a hypersensitivity reaction to medications, infections or allergens. It has also be associated with underlying malignancy, including solid organ tumors like colon cancer. An elderly man presented with anemia and a rash which was later diagnosed as CLCV. Further workup with colonoscopy lead to a diagnosis of colon adenocarcinoma. CLCV should be considered as a possible paraneoplastic phenomenon in the appropriate setting, to avoid delays in diagnosis and treatment of underlying malignancy.
Methods: An 84-year-old man with multiple comorbidities including coronary artery disease and diabetes mellitus presented to the emergency room with a 1-month history of worsening rash and exertional dyspnea. He had stable vital signs. Severe pallor and generalized maculopapular rash, especially in the extremities (Figure 1) was noted on examination. Hemoglobin was 5.0g/dl (13.5-18). He denied any known source of bleeding. Fecal occult blood was negative. No clear explanation for anemia was found and occult gastrointestinal bleed was suspected. Colonoscopy revealed a large semi-circumferential mass in the transverse colon (Figure 2) and biopsies confirmed a moderately differentiated invasive adenocarcinoma of the colon. No obvious metastasis was noted on CT scans. Skin biopsies showed perivascular infiltration by neutrophils, lymphocytes and nuclear debris, consistent with CLCV. Hemoglobin improved with blood transfusions. Surgical resection of tumor was discussed but deferred because of comorbidities and overall deconditioned state. Patient was discharged in stable condition for outpatient subspecialist follow up. Discussion: Colon adenocarcinoma causes significant morbidity and mortality and early diagnosis is crucial for effective treatment and patient survival. Paraneoplastic CLCV is rare but may develop in patients with colon adenocarcinoma and in a few cases has been the major presenting symptom or reflect recurrent disease. Treatment is mostly supportive and tumor resection may lead to resolution of rash. Underlying malignancy should be considered especially if a patient is not up to date with age-appropriate cancer screening. Increasing provider awareness of this uncommon association may help improve clinical outcomes.
Figure 1. Photograph of lower extremities showing coalescing maculopapular rash of cutaneous leukocytoclastic vasculitis.
Figure 2. Photograph showing adenocarcinoma (white arrows) in transverse colon during colonoscopy.
Disclosures: Kwabena Adu-Gyamfi indicated no relevant financial relationships. Sandeep Patri indicated no relevant financial relationships. Michael Maitar indicated no relevant financial relationships. Richmond Gyamfi indicated no relevant financial relationships.