A patient who had a history of 4 primary malignancies developed a rash that is usually seen among children. The 65-year-old man presented with a 2-day history of anasarca, painless skin lesions, and new arthralgias in both hands. He had a previous diagnosis of amyotrophic dermatomyositis, and although he had none of the typical skin manifestations of that disease on arrival at our institution, he did have associated interstitial lung disease. His medical history also included squamous cell lung cancer and cancers of the rectum, sigmoid colon, and urothelium. Four weeks earlier, he had undergone left nephroureterectomy for stage IV urothelial cancer complicated by postoperative atrial fibrillation and Clostridium difficile colitis. At that time, he was started on amiodarone and metronidazole.
Assessment
Examination revealed an alert, afebrile, normotensive man. Diffuse anasarca was particularly evident from his fingers to his forearms and his toes to his knees. He had dozens of isolated and linear violaceous, nonblanching, nonpruritic papules, plaques, and patches with central serous vesicles or bullae; the lesions erupted symmetrically along his upper and lower extremities (Figure 1, Figure 2). Nikolsky’s sign was not present. The rash was conspicuously absent over the patient’s chest, abdomen, back, and mucosal surfaces.
Blood tests revealed a hemoglobin level of 9.6 g/dL, a leukocyte count of 9.6 × 103 cells/mm3, and a platelet count of 410 × 103 platelets/µL. His international normalized ratio was 2.8 on warfarin, prothrombin time was 21.8 seconds, and partial thromboplastin time was 47.4 seconds. His D-dimer level was measured at 1706 ng/mL, lactate dehydrogenase level was 228 units/L, and fibrinogen level was 736 mg/dL.
Later, the patient reported sudden, diffuse abdominal pain. Yet, his abdomen was not tender on palpation. The surgical scar and Jackson-Pratt drain site from his recent surgery were nontender and nonpurulent. Abdominal radiography revealed no bowel obstruction or intussusception. Computed tomography of his abdomen and pelvis disclosed no abscess.
His creatinine level had increased from a postoperative result of 1.3 mg/dL to 1.7 mg/dL; his albumin level had decreased from 3.7 g/dL after surgery to 2.4 g/dL. Urinalysis revealed 2+ hematuria and 2+ proteinuria, but he had only 2 red blood cells per high-powered field. An initial albumin-to-creatinine ratio was 623 µg/mg, indicating mild albuminuria. The urine sediment revealed red blood cell casts surrounded by acanthocytes, a finding suggestive of glomerulonephritis (Figure 3). Renal biopsy was deferred, because the patient had a solitary kidney, and laboratory results did not suggest the risk involved in the procedure was warranted. An antinuclear antibody test was positive at 1:80 with a speckled pattern. Testing for antineutrophil cytoplasmic antibodies was negative.
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– Richard K. Kim, MD, MSc, Alyssa R. Thomas, BA, Mary Elizabeth Card, MD, Divyanshu Malhotra, MD, Jürgen L. Holleck, MD
This article originally appeared in the October 2017 issue of The American Journal of Medicine.
