LSU Medicine Case

Conference

Tuesday May 17, 2011

Gisella Tay, M.D.

Chief Complaint

“I fell down on my porch.”

HPI

• 60yo man with past medical history of HTN and recurrent sebaceous cysts was transferred from Lallie Kemp Medical Center for further evaluation. Patient initially presented to LKMC after having a syncopal episode 8 days prior to transfer to UH. Patient states he was on his front porch when he stood up and “passed out.” He denied any lightheadedness or dizziness prior to this episode. Per notes from LKMC, the patient was brought to the hospital by the his sisters after concern for his deteriorating health for the past few weeks. Patient has had decrease appetite with recent weight loss (at least a couple of pant sizes). He did have chills x 1 week but denied fever. He had increase fatigue and somnolence for 2 weeks and had been bedridden for one week prior to initial presentation.

ROS

• He admits to

– Edema of the feet for a couple of weeks

– Multiple skin nodules

– Sebaceous cysts on the face and neck

– Constipation

ROS

• He denies:

– Chest pain

– SOB

– Nausea or vomiting

– Abdominal pain

– Melena or hematochezia

– Hematuria

– Night sweats

Past History

• PMHx:

– HTN

– Recurrent sebaceous cysts (since

teenager)

• Surgical history:

– I & D of scalp and neck sebaceous cysts

Past History

• Meds:

– No home medications

• Allergies

– NKDA

Past History

• Social History:

– 25 pack year history, quit 1 month prior

secondary to “bad taste”.

– 20 year h/o EtOH use: one - fifth

whiskey/day, quit 2 months prior.

– Denies any illicit or IVDU.

– Lives with his sisters and nieces. No

children. Pt was in the Army for 10 years,

now retired construction worker

Past History

• FMHx:

– Father deceased at 70’s of MI

– Mother deceased at 70’s of CVA

• HM:

– No PCP. Not up to date on flu or

pneumococcal vaccine. Received Td

booster 1 week prior.

– No colonoscopy

Physical Exam

V/S: T 97.9OF HR 99 RR 22 BP 120/70

Sat 98% on RA Ht 6’3” Wt 220lb BMI 29 Pain 0/10

• Gen: A/O, NAD, flat affect, difficult to engage in conversation

• HEENT: PERRL, EOMI, OP clear, poor dentition, 3 non-purulent, tender open lesions with granulation on his posterior, occipital and frontal scalp measuring approximately 10cm, 6cm and 5cm in diameter. No bone exposure. 4cm firm subcutaneous nodule on right frontal scalp without any drainage.

Physical Exam

• Neck: Left sided nodule with a penrose

drain in place with minimal malodorous

serosanginous drainage. Right posterior

5cm nodule firm non tender

• CVS: RRR S1/S2. No murmurs or rubs.

No carotid bruit.

• Pulmonary: CTA B/L

• Abdomen: Bowel sounds present. Soft,

nontender, nondistended.

Physical exam

• Extremities: 3cm firm subcutaneous

nodule on left forearm without any

drainage. 2+ radial and dorsalis pedis

pulses bilaterally. Palmar hyperkeratosis

• Skin: No rashes or bruises. Scalp and

extremities lesions as described above

• Neuro: CN II-XII intact, no focal deficits,

generalized 4/5 weakness, no dismetria

finger to nose.

Laboratory Data

• WBC 19.7

• Hgb 12.3

• Hct 39.7

• Plts 422

• MCV 72

• RDW 16.9

• Segs 95 %

• Bands 0 %

• Lymphs 3 %

• Monos 2 %

• Eos 0 %

• Microcytes 2 +

• Hypocromic 2 +

Laboratory Data

• Na 139

• K 4.2

• Cl 101

• Bicarb 30

• BUN 20

• Creat 1.10

• Glucose 112

• TProt 6.4

• TBil 0.8

• Alb 3

• AST 27

• ALT 12

• Alk Phos 84

Laboratory Data

• Ca 12.7 Ca (c) 13.5

• Mg 1.8

• Phos 2.5

• PTH 8

• Cardiac enzymes neg

• UA wnl

• PT 14.1

• INR 1.2

• HIV neg

• Acute hep panel NR

• ETOH neg

• Utox neg

Laboratory Data

• Iron 20

• Transferrin 152

• TIBC 198

• Sat 10

• Ferritin 50.3

• ESR 32

• CRP 4.6

• UPEP and SPEP no

M spike.

• Blood Cx: NGTD

• Wound Cx: heavy

growth of MRSA

LAK Hospital Course

• Multiple draining cysts/abscesses on

scalp were I&D’d in the ED

• Vancomycin and clindamycin were

started upon admission

• General Surgery was consulted and

performed a granulation tissue biopsy

• Hypercalcemia treated with fluids

LAK Hospital Course

• Initial CXR concerning for atelectasis vs mass

• CT of head/neck/chest/abd/pelvis was done

with concern for spiculated mass in the

superior segment of the LLL with probable

lymphagitic carcinomatosis of LLL associated

with mild pleural thickening and a small

nodule in the superior segment of the RLL

• He was then transferred to University for

pulmonary and hematology/oncology

evaluation.

Admit ECG

CT head

Admit Chest X-Ray

CT Chest

Hospital Course

• While awaiting pathology slides done at LAK:

• Vancomycin and piperacillin/tazobactam

administered

• Pulmonary was consulted

– Bronchoscopy planned

• Dermatology was consulted and performed

punch bx of both scalp and forearm lesions

– Recommended continued wound care

Pathology

Anterior Scalp

Anterior Scalp

Anterior Scalp

Anterior Scalp

Left Forearm

Left Forearm

Diagnoses

• Skin, anterior scalp: Invasive

squamous cell carcinoma

• Skin, left forearm: Trichilemmal (pilar)

cyst

• Skin, frontal scalp: No significant

microscopic abnormality.

Hospital Course

• Pathology from the scalp lesion => invasive

squamous cell carcinoma

• Bronchoscopy cancelled

• Heme/Onc was consulted and complete

staging work up was done• Abd/pelvis negative; MRI c/w no definite extension of

the lesions into the brain but there was restricted

diffusion in some lesions in the right superior parietal

area. Early metastatic neoplasm in the right superior

parietal white matter could not be entirely excluded.

Diagnosis

• Stage 4 squamous cell carcinoma with

poor prognosis.

• Hospice recommended.