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By ZEESHAN TARIQ MD. CASE PRESENTATION. Presenting Complaint. 66 yr old black American with lower abdominal and back pain for the last 3 months. On and off pain with acute exacerbations. 6/10 intensity. Dull pain. Worsened by movements. Review of symptoms:
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By ZEESHAN TARIQ MD CASE PRESENTATION
Presenting Complaint 66 yr old black American with lower abdominal and back pain for the last 3 months. On and off pain with acute exacerbations. 6/10 intensity. Dull pain. Worsened by movements. Review of symptoms: H/o Constipation, no weight loss, anorexia or fever No H/o Numbness, tingling or urinary or fecal incontinence.
PAST MEDICAL HISTORY • Diabetes mellitus (Recently diagnosed) • Hypertension • Obstructive sleep apnea. • Psoriasis on steroids. • Lumbar spine # S/p Trauma
PAST SUGICAL HISTORY • Transplantation of ureters. • Hernia repair • Bilateral cataract removal Family History: Hypertension
SOCIAL HISTORY • Lives with his wife. • No h/o Smoking • No h/o Alcoholism • No h/o illicit drug use. Allergies: NKA
Examination • Middle age black American lying anxiously in bed well oriented in time space and person with vitals of: • BP: 143/86 • Pulse: 93 • R/R : 18 • Afebrile • Ox Sat : 95% on RA
Abdominal Exam: Soft abdomen Minimal abdominal tenderness. No visceromegaly Audible bowel sounds.
Examination • CVS: S1 + S2 + 0 • Resp : NVB no added sounds • CNS : Grossly Intact • Spinal tenderness +ve • Rash both lower extremities below both knee.
Investigations • Hb12.7 • WBC 6.9 • Ht 39.9 • Platelets 185 • BMP: Normal • Amylase 296 • Lipase 79 • UA: Normal
Liver function test • Bilirubin0.9 • ALT 22 • AST 23 • Alkaline phosph120 • Albumin 2.9 • Total Protein 5.8 • PT/INR 12.5/ 0.9 • PTT 20.0 • Lactic acid 1.6
Imaging • Abdominal X ray. Unremarkable Abnormal gas pattern • CXR: No acute changes. • Doppler LEX: Chronic DVT in distal femoral and popliteal veins.
Tumor markers • CA 19-9: 48 • CEA: 3.9 • Glucagon: 67 • PSA: 0.9
Summary • 66 year old came with lower abdominal and back pain. • Recently diagnosed DM 2 • Psoriasis on steroids • Spinal tenderness on percussion H/o Trauma • Slightly elevated pancreatic enzymes. • Left lower ext DVT
CT Abdomen • Area of low attenuation 17 x 9mm in the tail of pancreas with adjacent pancreatic duct dilatation. • Multiple renal cysts. • Multiple vertebral body compression fractures • Diverticulum along the lesser curvature of the second portion of the duodenum.
MRI Spine • Subacute compression fractures in the vertebral bodies of T10, T11 and T12 most likely due to osteoporosis. • Old L3 vertebral body compression fracture. Mild-to-moderate spinal canal stenosis seen at L2-3 level • Severe left-sided neural foraminal narrowing and moderate right-sided neural foraminal narrowing with impingement of the left L3 nerve root seen at L3-L4 level . • 5. Severe bilateral neural foraminal narrowing seen at L4-5 level.
ENDOSCOPIC ULTRASOUND • Periampullarydiverticulum • Dilated pancreatic duct more around tail of pancreas 2.6mm • Mutimicrocysticleisons at the tail of pancreas. • Each cyst measured 5-6 mm in size • 12x 19.4 cm whole collection of cysts. • CEA in fluid 278 • Amylase in fluid 499155 Units /L
Histopathology • Pancreatic aspirate: cystic mucinous neoplasm • Celiac lymph node biopsy: Inflammatory changes , no malignancy.
Key points • Newly diagnosed DM 2 • Trousseau s Syndrome.( DVT) • Necrolytic Migratory Erythema. (Psoriasiform eruption) • Slightly elevated pancreatic enzymes.
TROUSSEAU'S SYNDROME • An association between venous thrombosis and malignancy was first suggested in 1865 by Trousseau. • Unexplained deep venous thrombosis, followed a year later by the development of gastric carcinoma • In one review of patients with Trousseau's syndrome, the following associated tumors were seen : Pancreas — 24 percent Lung — 20 percent Prostate — 13 percent Stomach — 12 percent Acute leukemia — 9 percent Colon — 5 percent Common in mucin secreting adenocarcinoma.
Necroryltic Migratory Erythema: • Transient weeping eczematous or psoriasiform eruption • 70 percent of patients with glucagon-secreting pancreatic islet cell tumors. • Less frequently it has been seen with no glucagon-producing tumor, a condition termed pseudoglucagonoma syndrome. • Reported associations include celiac disease (from malabsorption), cirrhosis of the liver, inflammatory bowel disease, and various extrapancreatic malignancies, such as hepatocellular, lung, and duodenal cancer, and tumors that secret insulin or insulin-like growth factor II .
