A swollen finger and abdominal pain

Abstract

A 52-year-old Mexican-American male presented in February, 2000, with a 3-month history of progressive, painful swelling of his right ring finger after crushing it with a car jack. He denied other symptoms except for occasional lower abdominal pain and minimal weight loss over the past year. He did not smoke. His father had died of pancreatic cancer, but he had no other relevant family history. Physical examination showed a warm, ecchymotic, exquisitely tender distal fourth phalanx. Finger radiographs showed a lytic lesion suggestive of osteomyelitis and the patient was treated empirically with oral antibiotics. Blood tests showed iron-deficiency anaemia and an outpatient colonoscopy was ordered. However, 3 weeks later, a follow-up radiograph showed progressive destruction of the distal phalanx and increased soft tissue swelling (figure). The distal interphalangeal articular surface was intact. We incised and drained his finger. On exploring the wound, we found pinkish pulp and purulent material involving the entire distal phalanx but sparing the distal interphalangeal joint and the middle phalanx. We amputated the tip through the distal interphalangeal joint. Pathologic examination of the surgical specimen showed moderately differentiated adenocarcinoma. Culture of the specimen was negative except for minimal growth of common skin flora. Subsequent colonoscopy showed a sigmoid mass later proven to be invasive adenocarcinoma, with lung and liver metastases. Further treatment included proximal amputation of the involved finger, chemotherapy, and palliative radiotherapy for progressive bony metastatic disease. The patient died in January, 2001.