S2389 Greater Physical Exams Identify Leser-Trelat

Abstract

Introduction: Leser-Trelat sign, characterized by a sudden-onset explosion of seborrheic keratoses, is a rare cutaneous paraneoplastic syndrome indicative of an internal malignancy, most commonly rectal, gastric, and colon cancers, with gastric being the most frequent. We present a case of Leser-Trelat sign in the setting of no known malignancy and a periampullary tubulovillous adenoma. Case Description/Methods: Patient is a 77-year-old male with atrial fibrillation (on Apixaban), moderate cognitive impairment, type II diabetes, 57 pack-year smoking history, and prostate cancer (s/p resection in 2009) who presented with low energy, loss of appetite and a 20-pound unintentional weight loss over 1 month. On exam, he did not have any signs of overt bleeding, however, he had periumbilical hyperpigmented ill-defined patches and numerous diffuse warty hyperpigmented lesions throughout his back. Patient was uncertain how long the periumbilical darkening had been present; however, he stated that the lesions on his back developed suddenly 1 year ago. His labs on admission were notable with a hemoglobin of 4.8 (10.6 two months ago) and ferritin of 17. EGD and subsequent endoscopic ultrasound with fine needle aspiration showed a 3 cm non-bleeding, fungating periampullary duodenal mass consistent with a tubulovillous adenoma. Discussion: Patient presented with iron deficiency anemia, unintentional weight loss, Leser-Trelat sign, and acanthosis nigricans. This was concerning for a malignancy, however only a benign periampullary duodenal tubulovillous adenoma was found. Colonoscopy, CMP, CXR, SPEP and UPEP were normal. Patient is planning complete his malignancy and iron deficiency work-up with an outpatient CT scan and capsule endoscopy. Although further work-up is imperative to fully exclude a cancer given these classic malignancy associated skin findings, if no malignancy is found, this may be the first case of a tubulovillous adenoma demonstrating Leser-Trelat sign and acanthosis nigricans.Figure 1.: Leser-Trelat Sign.