CC: Masses, back pain, fatigue
ID: 58 yo incarcerated man with HTN and history of smoking/IVDU presents with soft tissue masses on his back and legs starting 3 months ago. He started to feel low back pain at this time, along with significant fatigue. Other symptoms include weight loss over the past 8 months and intermittent fevers the past 3 weeks. Exam was notable for firm masses on his R back, R buttock, and L inner thigh as well as bilateral pitting edema. BMP on admission was notable for hyperkalemia, hyperphosphatemia, anion gap metabolic acidosis and renal failure; additional labs ordered showed a uric acid level of 13.6 mg/dL and LDH >5000 U/L. MRI Lumbar spine showed enlarged bilateral paraspinal muscles with possible underlying mass and hematomas. CT images showed revealed extensive metastatic involvement of skeletal muscles and thoracic/retroperitoneal lymph nodes. The patient underwent an ultrasound-guided biopsy of the back mass; pathology revealed malignant melanoma. He was also diagnosed with tumor lysis syndrome (prior to any chemotherapy administration) and was started on IV fluids, allopurinol, and rasburicase.
Pearls from morning report:
- Allopurinol alone is insufficient to treat hyperuricemia since its action is in decreasing uric acid formation – use rasburicase for preexisting hyperuricemia.
- Be aggressive about IVF hydration! See the Pearls from 11/4/16 morning report for indications for renal replacement therapy in TLS.
- Spontaneous tumor lysis syndrome is rare, but is usually seen in Non-Hodgkin’s Lymphoma and acute leukemia.
President Jimmy Carter was diagnosed with metastatic melanoma to the liver and brain. He received immunotherapy with pembrolizumab and now reports he is now cancer free!
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