A 65-year-old man comes to the office due to fatigue, decreased appetite, and weight loss. He has lost 5.4 kg (12 lb) over the last 3 months and eats only small portions of food because he feels full soon after he begins eating. The patient smokes a pack of cigarettes per day and drinks alcohol socially. Blood pressure is 152/90 mm Hg and pulse is 90/min. Physical examination shows a firm, 3-cm lymph node above the left clavicle. There are also numerous skin lesions on his trunk, as shown below, which the patient notes have developed since the onset of his other symptoms. This patient's skin lesions most likely represent which of the following conditions?

Question

A 65-year-old man comes to the office due to fatigue, decreased appetite, and weight loss.  He has lost 5.4 kg (12 lb) over the last 3 months and eats only small portions of food because he feels full soon after he begins eating.  The patient smokes a pack of cigarettes per day and drinks alcohol socially.  Blood pressure is 152/90 mm Hg and pulse is 90/min.  Physical examination shows a firm, 3-cm lymph node above the left clavicle.  There are also numerous skin lesions on his trunk, as shown below, which the patient notes have developed since the onset of his other symptoms.  This patient's skin lesions most likely represent which of the following conditions?

Quizplus · Accepted Answer

11ec160b_3904_cd71_9249_497eee4f8421_MD0001_00 This patient's weight loss, early satiety, positive smoking history, and left supraclavicular adenopathy are concerning for gastric adenocarcinoma (GA). Patients with GA can also have epigastric pain, hematemesis, and occult blood loss in the stool. Physical examination findings in advanced (metastatic) disease include left supraclavicular (Virchow node) or left axillary lymphadenopathy, or a periumbilical mass (Sister Mary Joseph nodule). In addition, rapid onset of numerous seborrheic keratoses (pigmented macules or plaques with a greasy surface and well-demarcated borders) is a classic indicator of internal malignancy (Leser-Trélat sign), particularly GA, and is thought to occur in response to increased tumor production of cytokines or growth factors (eg, IGF-1, fibroblast growth factor). Acanthosis nigricans (a hyperpigmented skin disorder typically associated with insulin resistance) can also occur in malignancy due to a similar mechanism (Choice A). (Choice B) Melanoma characteristically presents as an asymmetric, pigmented lesion with an irregular border, variable coloration, and change in size and appearance over time. Lesions that are multifocal, monotonous, and otherwise asymptomatic are more typical of seborrheic keratoses. (Choice C) Cutaneous neurofibromas are soft, mobile tumors that are occasionally hyperpigmented. They are often solitary and sporadic, although numerous lesions may occur in neurofibromatosis types 1 and 2. However, these inherited disorders typically present in childhood or young adulthood, and type 1 (the more common type) is also characterized by axillary freckling, café-au-lait macules, and iris hamartomas. (Choice D) Psoriasis is an inflammatory dermatosis characterized by well-demarcated plaques with silvery scales. It can affect the trunk but is more common on extensor surfaces of the extremities. Explosive onset of psoriasis is associated with HIV infection. (Choice F) Tuberous sclerosis is an inherited neurocutaneous syndrome. Cutaneous findings include hypopigmented macules, periungual fibromas, connective tissue nevi, forehead fibrous plaques, and facial angiofibromas. Educational objective: Seborrheic keratoses are pigmented macules or plaques with a greasy surface and well-demarcated borders. Rapid onset of numerous lesions is an indicator of internal malignancy (Leser-Trélat sign), especially gastric adenocarcinoma.

A 65-Year-Old Man Comes to the Office Due to Fatigue