A 53-year-old African American woman with progressive shortness of breath for 1 month and a productive cough with intermittent blood-tinged sputum sought treatment at our emergency room. Over the past 2 months, she had lost 20 pounds—despite a normal appetite—and had noticed multiple “bumps” on her body.
The patient had no changes in her bowel habits, nor had she experienced nausea, vomiting, hematochezia, hemoptysis, odynophagia, dysphagia, chills, fever, or night sweats. Her past medical and surgical histories were unremarkable.
She had a 40-year history of smoking 1 to 3 packs of cigarettes per day, and a 30-year history of drinking a 1-liter bottle of hard liquor a day. She also occasionally used marijuana.
While in the ER, the patient was comfortable breathing on room air and afebrile with stable vital signs. We noticed decreased breath sounds bilaterally, as well as rhonchi. The patient had diffuse lymphadenopathy, as well as multiple, fixed, painless subcutaneous nodules on the neck, arms, flanks, back, and proximal right thigh. There was a 4 × 3.5 cm exophytic beefy-red tumor on the left inner arm (FIGURE 1). Some smaller nodules had surface hyperpigmentation, while others were subcutaneous, with no epidermal surface changes. All of the lesions were asymptomatic.
We ordered a chest radiograph (FIGURE 2) and blood work. Abnormal hematologic test results were: alkaline phosphatase (236 IU/L), gamma-glutamyl transferase (435 IU/L), and serum Ca++ (8.2 mg/dL).
FIGURE 1
Tumor on left inner arm
FIGURE 2
Chest x-ray brings Dx into focus
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