Barrett Attarha, DO1, Satish Maharaj, MD1, Ciel Harris, MD1, Ron Schey, MD1, Ammar Nassri, MD1, Elisa Sottile, MD2, Lauren Stemboroski, DO2
1University of Florida College of Medicine, Jacksonville, FL; 2University of Florida Jacksonville College of Medicine, Jacksonville, FL
Introduction: We present a case of a patient who presented with abdominal pain and a small bowel obstruction and was found to have renal cell carcinoma causing a paraneoplastic vasculitis affecting his bowel.
Case Description/Methods: A 57 year old Caucasian male with no significant past medical of family history presented to the Emergency Department complaining of a 2 day history of severe abdominal pain, nausea, vomiting and a bilateral non-blanching rash on his lower extremities that extended up towards his umbilicus (Figure 1). Initial XR Abdomen revealed a small bowel obstruction. A CT abdomen/pelvis was done which showed focal bowel wall thickening of distal duodenum and proximal jejunum with some mucosal edema and stranding of adjacent mesenteric fat concerning for duodenitis/enteritis. A CT renal mass protocol was ordered which revealed a 3.1cm enhancing left renal mass highly suspicious for Renal cell carcinoma. An NG tube was inserted for decompression. On day three of admission patient had EGD performed which revealed multiple partially obstructing ulcerations throughout the second and third portion of the duodenum (Figure 2 and 3). Biopsy samples of the duodenum showed severe active duodenitis with erosions that was negative for CMV. A colonoscopy revealed an ulcer at the ileocecal valve which was biopsied and showed acute inflammation. There was non-specific erythematous mucosa throughout the colon. The patient began to experience swelling and pain in his wrist and the small joints of his hand and the rash continued to spread. Rheumatology performed an autoimmune workup which was normal save for mildly elevated C3, C4 and a high CRP. An extensive infectious disease workup was negative. Skin biopsy of the lesion was consistent with medium/large vessel vasculitis and the patient was started on high dose steroids. The patients clinical course improved drastically and he was discharged on a prolonged steroid taper. He underwent a nephrectomy 1 month from hospital discharge with pathology revealing clear cell renal cell adenocarcinoma with clear margins. He was continued on a steroid taper until resolution of his symptoms at 6 months follow up.
Discussion: Paraneoplastic vasculitis in patients with solid tumors has been described, and can very rarely affect the gastrointestinal tract. It can cause local or diffuse pathologic changes in the gastrointestinal tract, resulting in nonspecific paralytic ileus, mesenteric ischemia, submucosal edema, hemorrhage, or even bowel perforation.
Citation: Barrett Attarha, DO; Satish Maharaj, MD; Ciel Harris, MD; Ron Schey, MD; Ammar Nassri, MD; Elisa Sottile, MD; Lauren Stemboroski, DO. P1723 - RENAL CELL CARCINOMA PRESENTING AS PARANEOPLASTIC SYNDROME INVOLVING THE GASTROINTESTINAL TRACT. Program No. P1723. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.