Medical Grand Rounds Clinical Vignette

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Medical Grand RoundsClinical Vignette

• Sherley Abraham, MD
• January 23rd, 2008

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Chief Complaint

• 47 year old, African American male prisoner with
  no significant past medical history presenting
  with 4 months of Left arm and axillary pain and
  swelling.

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History of Present Illness

• Left upper arm swelling extending to axilla,
  causing pain and restriction in movement,
  worsening over 4 months.
• He reported night sweats, but denied fevers,
  weight loss, chest pain, dyspnea, or weakness.

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History

• Past Medical History none
• Past Surgical History none
• Allergies none
• Medications none
• Social History prisoner, remote tobacco history,
  social alcohol use, denied drug use
• Family History no family history of malignancy

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Physical Exam

• General well-nourished African American man in
  no acute distress
• VS T 102F, BP 121/50, P 115, RR 18, O2 sat 97
  RA
• Lymph Nodes large left axillary mass, fixed,
  firm 5 cm x 5 cm bilateral 2 cm neck and
  supraclavicular nodes, fixed, firm
• Skin significant for 4mm hypopigmented indurated
  papule on left abdomen.
• Lungs decreased breath sounds at left base,
  bilateral wheezes
• Abd normal bowel sounds, soft, non-tender,
  hepatosplenomegaly
• The remainder of the exam was normal

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Laboratory Values

• Hb/Hct 10.9/33 MCV 90
• AST 72, ALT 66, Alk Phos 182, TBili 0.4, DBili
  0.2, TP 7.8, Alb 4.1
• LDH 577
• HIV negative

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Data

• CT Chest L pleural effusion, extensive
  medistinal, hilar, axillary and supraclavicular
  lymphadenopathy, innumerable lytic bony lesions
  in thoracic spine, sternum, clavicles, ribs,
  scapula, L humeral head
• CT A/P extensive osseus lytic lesions,
  splenomegaly with hypodense lesions, upper
  abdominal and retroperitoneal lymphadenopathy
• CT Head lytic lesions in calvarium, no brain
  lesion
• CT Spine spinal lytic lesions with T6
  compression fracture
• Bone Scan osteoblastic lesions in sternum and
  ribs
• Upper extremity Duplex no DVT

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Working Diagnosis

• Malignancy including Multiple Myeloma, Lymphoma,
  and Metastatic Disease (colorectal cancer,
  prostate)

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Hospital Course

• Patient underwent excisional biopsy of axillary
  lymph node, bone marrow biopsy, and punch biopsy
  of abdominal skin lesion

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Pathology

• Left axillary lymph node melanoma
• Bone Marrow Biopsy melanoma
• Skin Biopsy superficial scar
• Left pleural fluid showed no evidence of
  infection, consistent with malignant effusion

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Hospital Course

• Patient received Chemotherapy temozolamide and
  palliative XRT for T6 compression fracture
• Patient was granted compassionate release from
  prison
• Full Skin exam and Ophthalmic exam were
  unrevealing
• Hospital course complicated by left upper
  extremity DVT
• Developed progressive weakness and worsening
  respiratory distress, made comfort care, expired
  during hospitalization nearly 3 months after
  admission

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Final Diagnosis

• Metastatic Malignant Melanoma
• Diffusely metastatic to bone marrow, bones, and
  lymph nodes
• No primary lesion could be identified