SCIENTIFIC
Cutaneous Clues to Lung Cancer: Leukocytoclastic Vasculitis as a Paraneoplastic Syndrome in Adenocarcinoma of the Lung
AUTHORS:
ABSTRACT
Christopher Allawh, OMS-III 1 Blake Prieskorn, OMS-III 1 Salam H. Rajjoub, MD 1
AFFILIATIONS:
1
West Virginia School of Osteopathic Medicine
CORRESPONDING AUTHOR:
Christopher Allawh, OMS-III callawh @ osteo. wvsom. edu
DISCLOSURES: None
ETHICS STATEMENT: Permission was obtained from the patient.
FUNDING: None
CASE PRESENTATION
A 55-year-old patient presented with intermittent recurrent sinusitis approximately seven times per year and approximately eight years after being diagnosed with right hilar adenocarcinoma. The findings of the computed tomography angiogram of the chest with intravenous contrast revealed extensive bilateral pulmonary emphysema and a coarse, masslike focus lateral to the right hilum measuring 1.9 cm x 3 cm. A biopsy of the right lung nodule showed neoplastic cells in nests and glandular formation with rare intranuclear inclusions and tumor cells positive for cytokeratin 7 and thyroid transcription factor-1 immunohistochemica l profiles, consistent w it h lung adenocarcinoma. The subsequent positron emission tomography and computed tomography( CT) imaging performed six years after diagnosis of adenocarcinoma showed partial opacification of the right maxillary sinus and ethmoidal air cells significant for inflammatory sinus disease, moderate centrilobular emphy-
A 55-year-old patient with a history of chronic obstructive pulmonary disease presented with recurrent sinusitis, progressive weight loss, and the development of a skin rash on bilateral lower extremities. Past medical history was significant for a right hilar mass with a biopsy confirming the diagnosis of adenocarcinoma. Given the patient’ s systemic manifestations, paraneoplastic vasculitis was suspected and supported by
sematous changes, and no change in the right hilar mass. Additionally, the CT scan demonstrated no extra-thoracic evidence of malignancy and the right hilar lesion appeared stable showing post radiation changes.
A repeat CT scan seven years after diagnosis of adenocarcinoma demonstrated stable post-radiation changes without evidence of recurrent or metastatic disease. Following the diagnosis of adenocarcinoma, the patient was treated with radiation therapy and started on rituximab( RTX). The patient presented to the office complaining of recurrent epistaxis and bilateral lower extremity rash as visualized in Figure 1, eight years after initial diagnosis of adenocarcinoma. A review of systems revealed fatigue, unintentional weight loss, hoarseness, headaches, and rash on the lower extremities bilaterally. Due to concern for vasculitis, the following laboratory studies were obtained: myeloperoxidase( MPO) antibody, cytoplasmic anti-neutrophil cytoplasmic antibody, perinuclear anti-neutrophil cytoplasmic antibody, proteinase 3, eosinophils, and hepatitis B and hepatitis C screens. The patient’ s significant laboratory results were an MPO level of 545 pmol / L( reference range normal: 0-469 pmol / L), an eosinophil value of 0.10( within normal limits), and negative hepatitis B and C screens. The patient was sent to dermatology for a biopsy of the lower extremity, confirming leukocytoclastic vasculitis a positive myeloperoxidase antibody value of 545 pmol / L( reference range normal: 0-469 pmol / L) and was confirmed with a skin biopsy of the lower extremity revealing leukocytoclastic vasculitis. This case highlights the potential link between adenocarcinoma and the development of vasculitis, underscoring the importance of considering paraneoplastic syndromes in patients presenting with unexplained vasculitis.
( LCV). Vasculitis improved after being treated with 0.6 mg of colchicine once daily.
DISCUSSION
LCV is a small vessel vasculitis characterized as an inflammatory process that directly affects the dermal capillaries and venules. The incidence of LCV, based on biopsy-confirmed cases in a population-based study, has been estimated at approximately 45 per 1 million individuals. 1 This vasculitis can result from different factors, including the following: post-infectious causes( i. e., hepatitis B, hepatitis C, Streptococcal upper respiratory tract infections, and syphilis), medications( i. e., beta-lactams, erythromycin, clindamycin, vancomycin, sulfonamides, furosemide, allopurinol, and valproic acid), and paraneoplastic syndromes as in the case of our patient. Paraneoplastic syndromes are a clinical phenomenon directly linked to tumor-derived factors and immune cross-reactivity. There has been an established link between lung cancer, specifically adenocarcinoma, and paraneoplastic manifestation of vasculitis that may either precede or coincide with the diagnosis of malignancy. 2 Cutaneous vasculitis has been found to have a closer association with hematologic malignancies; several reports have documented its occurrence in solid tumors, such as lung adenocarcinoma. 3 The appearance of LCV in a patient can serve as a clinical cue for further analysis of occult malignancies.
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