PGY3 April Choi presented a case of a 64 y/o M with history of hypothyroidism, CVA, Chagas cardiomyopathy c/b achalasia and malignant intractable arrhythmia s/p OHT 8/2019 with post-op complications of primary graft dysfunction, renal failure, esophageal perforation and multiple infections, now presents with inability to tolerate PO x2-3 weeks. Patient was previously seen in the transplant clinic 1 month prior at which tie he was feeling well but was having issues with eating due to a persistent lack of taste since transplant. Now he is unable to keep down solids, vomiting with each meal, occasional diarrhea, associated with severe whole body weakness x10 days. Medications include mycophenolate mofetil 500mg BID, prednisone 5mg qday, tacrolimus 1mg BID, Bactrim DS MWF and fluconazole 200mg qday. He was born in Mexico and denies any tobacco/alcohol/drugs.
Vitals: T 35.7, HR 105, RR 20, BP 104/71, O2 sat 90% RA
Physical Exam significant for regular cardiac and pulm exam, two reducible umbilical hernia, no JVD or lower extremity edema, skin with no lesions/rashes.
CBC: WBC 9.45> Hb 9.1/Hct 31.6 <Plt 406 (MCV 103.6, RDW 14.8%)
Diff: 80.9% PMN, 5.2% lymph, 13% monocytes, 0% eosinophils, and 0% basophils
Na 136/K 5.5/Cl 96/HCO3 26/BUN 41/Cr 7.06 <Glucose 58
ALP 190>T.protein 6.2/Albumin 3/AST 19/ALT 11/Tbili 0.4
Coags: PT 13.9, INR 1.0
CT Thorax showed numerous new and increased pulmonary nodules and masses, the largest of which abuts the pleura in the RML.
- BCx: 1/4 positive for Cutibacterium (Propionibacterium) acnes in aerobic bottle
- COVID-19 negative
- Procal 2.74
- Acute hepatitis panel
- Hep A IgM negative
- Hep B core IgM negative
- Hep B surface Ag negative
- Hep C Ab: negative
- Cocci Ag/Ab negative
- Histo Ag not detected
- T. cruzi PCR negative
- Quant gold negative
- CMV DNA PCR detected, CMV DNA PCR Quant <34.5
- EBV not detected
- AFB Blood culture negative
- Sputum Culture 3+ normal upper respiratory flora
CT A/P showed new innumerable lesions in the liver, new intra, extra and retroperitoneal nodules in the L hemiabdomen and pelvis, periportal lymphadenopathy and L adrenal nodule.
EGD: mild gastropathy. Biopsies taken for eosinophilic esophagitis given dysphagia. Mild gastropathy.
Liver biopsy done showed metastaic melanoma.
Treatment: Derm and Ophtho consulted with no primary tumor noted on skin and no evidence of primary tumor in the uveal tract. Patient underwent palliative radiation to the large R lung mass. He was started on Trametinib given loss of NF1 before being hospitalized again for PO intolerance.
Take home points:
- Melanoma is an immune driven malignancy.
- Post-transplant malignancies account for 10-47% of deaths in solid organ recipients. Death from post transplant malignancies at 5-10 years after transplant is 215% for heart transplant recipients.
- Most common post-transplant malignancies are the non-melanoma skin cancers (BCC and SCC) and PTLD (Post-Transplant Lymphoproliferative Disease).