CASE PRESENTATION

ByZEESHAN TARIQ MD

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

Hb 12.7

WBC 6.9

Ht 39.9

Platelets 185

BMP: Normal

Amylase 296

Lipase 79

UA: Normal

Liver function test Bilirubin 0.9

ALT 22

AST 23

Alkaline phosph 120

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.

MRI Spine

ENDOSCOPIC ULTRASOUND Periampullary diverticulum

Dilated pancreatic duct more around tail of pancreas 2.6mm

Mutimicrocystic leisons 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.

Histopathology

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 .

Psoriasiform Eruption:

Thank you