044. PARANEOPLASTIC VASCULITIS IN OCCULT LUNG MALIGNANCY

Abstract

Background: Paraneoplastic syndromes are localized or diffuse pathologic manifestations that may occur in subjects affected by neoplastic diseases. Among the multiple clinical manifestations of paraneoplastic syndromes, cutaneous presentations are quite common. It is estimated that in about 1% of cases, skin manifestations may represent the first diagnostic sign of a neoplastic disease. We report a case of paraneoplastic vasculitis in a patient with occult lung malignancy. Methods: A 78 year old lady, presented with six week history of pain and discolouration of a right middle finger. She was known to have rheumatoid arthritis but otherwise well. On examination, right middle finger pulp appeared necrotic at the tip and was tender to palpation. She had facial telangiectasia and splinter haemorrhages in both hands. The distal pulses in all the limbs were present, however, peripheries were cold. She was tachycardic with a pulse of 109 bpm but the remaining observations were normal. There were no eye signs, rash or joint pain. Her systemic examinations were unremarkable. The initial laboratory results were: Hb 91 g/L, WCC 27.3 × 109/L, Platelets 437 × 109/L, GFR >90 ml/min, CRP 172 mg/L, CK 25 with normal liver function. ECG showed sinus tachycardia, chest X-ray showed an illdefined small opacity in the right middle zone and urine dipstick showed haematuria. The initial clinical impression was infective endocarditis, however, vasculitis was also a differential. The transthoracic echocardiogram did not show any vegetations and three sets of blood cultures were negative. The immunology and vasculitic screen were normal. Results: She was started on dual anti-platelet therapy and iloprost infusion for the ischeamic finger. She was also started on prednisolone 40mg once a day for the likely autoimmune vasculitis. Later, she developed pain in the left foot. On examination, she had paraesthesia in her toes and lateral aspect of the sole along with calf tenderness. Ultrasound Doppler did not show any evidence of venous thrombosis. The pain and numbness progressed to both lower limbs. Her finger discolouration and pain started to improve with three iloprost infusions. Computed Tomography of the thorax showed a lesion in the right upper lobe suspicious for malignancy with no distant metastasis. She underwent percutaneous biopsy of the lung lesion which confirmed Adenocarcinoma. A diagnosis of vasculitis secondary to paraneoplastic syndrome was made and the patient was planned to have a right lobectomy. Conclusion: Case series have shown resolution of vasculitis following the effective treatment of malignancy. Any recurrence of vasculitis is a marker of tumour recurrence or progression, thus providing strong evidence for vasculitis being a true paraneoplastic syndrome. Vasculitis with poor response to usual therapy, especially in elderly patients, should raise a question about underlying malignancy.