Scleritis as a Presenting Sign of Stage IV Lung Adenocarcinoma

Abstract

SESSION TITLE: Non-Small Cell Lung Cancer SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Scleritis is attributed to an underlying systemic disease in up to 50% of cases, with infections recognized as the cause in another 7% of cases. Non infectious scleritis occurs in the setting of rheumatologic disorders, surgery, and rarely malignancies. While infectious and noninfectious scleritis are often indistinguishable, the treatments are anything but uniform. Our case emphasizes the importance of early clinical suspicion for malignancy as a cause of treatment resistant scleritis. CASE PRESENTATION: A 56 year old West African male with HIV on antiretroviral therapy (CD4 694) presented from a community ophthalmology clinic with progressive vision loss of the left eye (OS), increased lacrimation, and pain for one month despite topical steroid therapy. While he endorsed a 20lb weight loss he denied any headaches, trauma, fevers, chills, night sweats, cough, hemoptysis, rashes or similar prior episodes. Exam revealed decreased visual acuity limited to hand motion and 3+ injection OS. Right eye exam was benign. He was diagnosed with anterior and posterior scleritis, a serous retinal detachment and a sub-retinal mass OS. Workup was notable for ESR 55mm/hr, and CRP 93mg/L but normal ACE, ANCA, ANA, RPR, Lyme Ab, Quantiferon Tb gold, RF, and HLA-B27. Chest X-ray revealed a right upper lobe (RUL) mass with a small right effusion. CT chest showed a 7cm RUL mass, adenopathy, and a right chest wall mass. Further imaging showed metastatic disease involving the adrenals, kidney, diaphragm, and spine. MRI of the brain and orbits revealed multiple brain metastases and a retinal detachment OS. Biopsy confirmed a diagnosis of metastatic lung adenocarcinoma. DISCUSSION: While the eye is a rare site of malignancy in adults, metastatic spread from primary breast, lung, or gastrointestinal cancers constitute the majority of cases. In fact, ocular metastases most often occur in patients with a prior known malignancy diagnosis. Lung cancer, in contrast, often metastasizes early to the uveal tract, with ocular metastasis representing the first sign of disease. While serous retinal detachments due to choroidal metastasis are well documented, malignancy-associated scleritis is rare and reported in only a few case reports. Our case demonstrates two potential vision compromising complications of choroidal metastasis as the presenting signs of underlying lung cancer, specifically serous retinal detachments and scleritis. CONCLUSIONS: Scleritis as an initial presentation of metastatic cancer may be rare, however, it has been described in the literature. As in this case, there are times when scleritis is the first and only sign of deeper underlying pathology. It is thus prudent to investigate each case of scleritis in depth. If routine treatments do not promptly lead to resolution of symptoms, then the differential should expand to include systemic diseases such as malignancies. Reference #1: Cohen VML. Eye. 2013;27(2):137-141 Reference #2: Diaz JD. et al. Surv Ophthalmol. 2016;61(6):702-717 DISCLOSURE: The following authors have nothing to disclose: Matthew Wieder, Ana Velazquez, Margarita Chernovolenko, Veevek Anand Agrawal No Product/Research Disclosure Information