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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
Examination
CVS: S1 + S2 + 0
Resp : NVB no added sounds CNS : Grossly Intact
Spinal tenderness +ve
Rash both lower extremities below both knee.
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.
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.
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.
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 .