A 40-Year-Old African American Woman With Sickle Cell Trait, a Renal Cell Mass, and an Ulcerated Scalp Lesion

Abstract

Patient: 40-year-old African American woman. Chief Complaint: Painless hematuria. History of Present Illness: The patient had 2 episodes of painless gross hematuria before seeking treatment in our emergency department; she reported no other symptoms. Her urinalysis results were positive for hemoglobin and revealed more than 50 red blood cells per high-powered field on microscopic examination. A 3-phase computed tomography (CT) scan revealed an enhancing 3.9 × 2.5 cm lesion in the superior/interpolar region of the right kidney, which suggested renal cell carcinoma or transitional cell carcinoma. A renal biopsy guided by the CT image was not diagnostic. A nephrectomy was performed. Family History: The patient’s maternal grandmother had died of breast cancer. Social History: The patient reports never being a smoker and reports no recreational drug use. Follow-up: Two months after her nephrectomy, a positron emission tomography (PET) scan performed on the patient did not reveal metastatic disease. Two months later, she developed a painful scalp lesion, which slowly grew over the next several months, eventually ulcerated, and did not heal despite appropriate wound care. A biopsy of the lesion had a histologic appearance similar to that of the nephrectomy specimen. Shortly after undergoing skin biopsy, the patient developed new-onset abdominal pain and sought treatment in the emergency department. A computed tomography (CT) scan of her abdomen and pelvis revealed a 1.1 cm pulmonary nodule with mass effect, in a lung base that was suggestive of metastatic disease. A 1.8-cm soft-tissue mass arose at the resection site with a differential diagnosis of recurrent disease or scarring. A positron emission tomography (PET)-CT scan was subsequently performed, which revealed recurrent disease in the right renal fossa and diffuse abdominal and pulmonary metastatic disease. The patient underwent a follow-up skin biopsy. 1. What are this patient’s most striking clinical, laboratory, and radiologic findings? 2. This …