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Lung Cancer |

Lung Cancer With Unusual Presentation

Pius Ochieng, MD; Georges El-hayek, MD; Gopal Narayanswami, MD
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St Luke's Roosevelt Hospital, New York, NY


Chest. 2013;144(4_MeetingAbstracts):623A. doi:10.1378/chest.1700856
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Abstract

SESSION TITLE: Cancer Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Vasculitis is rare manifestation of malignancy and is usually observed in hematological more than solid tumors. We present a case of lung cancer presenting as a rash with eosinophilia.

CASE PRESENTATION: A 70 year male former smoker presented with one week of rapidly spreading pruritic purpuric rash on limbs. He reported no sick contacts, insect bites or new medication. Examination revealed diffuse palpable purpura on the extremities and trunk. Laboratory tests showed leukocytosis with eosinophilia, normal comprehensive metabolic panel, normal Urinalysis, negative hepatitis panel, HIV and tests for various rheumatologic conditions and vasculitidis. Chest radiograph revealed right upper lobe mass which was confirmed by CT scan. Skin Biopsy was consistent with leukocytoclastic vasculitis. Lung mass biopsy revealed large cell carcinoma. The cancer was stage IIIB and was treated with chemotherapy with resolution of the skin lesions.

DISCUSSION: The atypical presentation of the lung cancer with pruritic rash and eosinophilia makes this case unique. This presentation could trigger a diagnostic heuristic of an allergic rash but solid tumors including all types of lung cancers may be associated with eosinophilia. Given the negative serology for other diseases and the resolution of the rash with treatment of the lung cancer, this patient’s leukocytoclastic vasculitis was likely a paraneoplastic syndrome related to large cell lung carcinoma. Malignancy accounts for 4% of cases cutaneous vasculitis but leukocytoclastic vasculitis has been associated with hematological rather than solid malignancies. Lung cancer related leukocytoclastic vasculitis has been reported rarely and in these cases in association with adenocarcinoma and small cell lung cancer. The mechanism by which neoplasm causes cutaneous vasculitis is unclear. Theories include auto-immune inflammatory reaction against the small blood vessels due to tumor-antigen induced immune complexes deposition on blood vessel walls, tumor embolism, vascular invasion and tumor derived cytokines related injury. Primary treatment for paraneoplastic leucocytoclastic vasculitis is therapy for the underlying malignancy. Other useful therapies include corticosteroids, other immunosuppressants and antihistamines.

CONCLUSIONS: Although rare, paraneoplastic vasculitis may be the presenting feature of lung cancer.

Reference #1: Matsumoto S, et al: Lung cancer with eosinophilia in the peripheral blood and the pleural fluid. Intern Med 31: 525-529, 1992.

Reference #2: Solans LR, et al: Paraneoplastic vasculitis in patients with solid tumors: Report of 15 cases. The Journal of rheumatology 35:294-304, 2008.

Reference #3: Kathula SK, et al: Paraneoplastic Cutaneous Leukocytoclastic Vasculitis and Iron Deficiency Anemia As the Presenting Features of Squamous Cell Lung Carcinoma. Journal of Clinical Oncology 29(4): e83-e85, 2011.

DISCLOSURE: The following authors have nothing to disclose: Pius Ochieng, Georges El-hayek, Gopal Narayanswami

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