27 Nov 2020

11/9/20: Angiosarcoma in a post-renal transplant patient

PGY3 Ashil Panchal presented a case of a 68 year old male with history of Type II DM, ESRD s/p renal transplant 2014 c/b cryptococcus pneumonia and nephrolithiasis in transplant kidney c/b klebsiella urosepsis s/p PCNT for hydronephrosis presents with 3 weeks of worsening nonhealing wound at his RUE AVF site along with worsening fatigue and weakness leading to several falls at home.  Patient denies fevers, chills, cough, SOB, n/v, dysuria or hematuria.  He does have new persistent weakness, fatigue, decreased ADLs and decreased appetite.  He has soreness at RUE AVF site with the ulcer growing in size over the last several months.  No significant drainage.  Of note, the patient was noted to have an AVF aneurysm and rupture 4 months prior s/p ligation and excision.  Home medications include fluconazole, tacrolimus and prednisone.

Vitals: T 37.1, HR 113 (supine), 143 (sitting), RR 18, BP 131/66 (supine), 83/47 (sitting), O2 sat 98% on RA

Physical Exam significant for thin, frail male, comfortable appearing, A&Ox4, b/l temporal wasting, multiple ecchymosis on face from prior falls, tachycardic, clear pulm exam, anterior PCNT in place with clear yellow urine and R forearm 6cm x 4cm wound with granulation, necrotic wound edges, superficially packed with gauze and xeroform, no purulent drainage, palpable brachial and radial arteries.

CBC: WBC 6.46> Hb 7.7/Hct 25.8 <Plt 437 (MCV 93.5, RDW 17%)

CMP:

Na 133/K 4.8/Cl 93/HCO3 28/BUN 18/Cr 1.24 <Glucose 244 (baseline Cr 1.2)

ALP 67>T.protein 6.2/Albumin 2.5/AST 21/ALT 55/Tbili 0.4

Ca 8, Mg 1.5, Phos 3

Coags: PT 16.6, INR 1.3

Infectious workup started with the following significant results:

  • BCx negative
  • Wound Cx: 2+ enterococcus faecalis, staph epidermidis
  • Tissue Cx: negative for fungal, AFB growth
  • Viral serologies (EBV, CMV, COVID-19) negative
  • Fungal serologies positive for Crypto Ag 1:10

Dermatology was consulted and a punch biopsy was performed, resulting in angiosarcoma.

Treatment: After diagnosis, there was plans for taxol initiation, but the patient decompensated during the hospitalization due to multiple acquired infections due to his immunocompromised state and he was upgraded to the ICU for further care.

Teaching points:

  1. Mycobacterium that like cooler temperature: M. marinum and M. chalonae and so will see them more on the extremities.  Fungus that tend to have vascular invasion: Aspergillus and Rhizopus spp.
  2. Post-transplant patients have a 2-3 times higher risk for malignancy.  Risk factors include: type/duration/extent of immunosuppression (calcineurin inhibitors suppress T cell immunity) and oncogenic viruses.
  3. Most common malignancy seen in post-transplant patients: skin/lip/PTLD/anogenital/Karposi sarcoma (associated with HHV8)/renal cell.  It is important to have regular skin cancer screening and age appropriate malignancy screening for these patients.

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